Hello and welcome. Thank you all for joining us. Today we're going to be talking about autologous fat grafting to the hand. So if you are in the wrong ICL, that's what we're talking about in this room. So that's first and foremost. If you need to run out, go ahead. But I'm Paige Fox, and I'm here from Stanford, and I have a great panel with me. One of my panelists is missing due to some uploading issues, but she'll be here soon. That's Heather Baltzer. She is the Donna Nita Reed Professor in Hand Surgery and the Chief of Plastic Surgery at the University Health Network at the University of Toronto. And then next up here on the panel here is Dr. David Kohlberg. He is a Professor of Surgery at Cedars-Sinai. And both of these people are doing lots of fat grafting in the hands and are gonna talk to us today. Dr. Baltzer's gonna talk to us about some techniques and indications and contraindications. And then Dr. Kohlberg is gonna dive into the cases and how you actually use this. And just by a show of hands, how many people here are doing some fat grafting in the hand? Okay, a couple people, great. And hopefully the rest of you are here to learn what it's all about and see if it's something you wanna incorporate in your practice. I'm gonna start out, I've been charged, or I charged myself with the autologous fat grafting, really talking a little bit about the science. And if you know a lot about the science, I'm gonna go at a superficial level here. I just wanna kinda talk about why the techniques and things that we use are important as far as based on the basic science. So no disclosures. So really, fat, why is it attractive to us? And it's really attractive because it has three properties that are great when we think about some problems that we have in the hand. It has anti-inflammatory properties, pro-angiogenic properties, and regenerative properties. And inside the fat, we all think about fat as just the adipocytes, or the fat cells. But that's not truly what the important, if you will, part of fat grafting is. It's not just the fat. So you also have stem cells that are in there, and growth factors that are in there. And it's really those things together that make up the magic of fat. So this is adipocytes, so this is just out, this is what I do. This is by hand suction fat grafting. And the adipocytes are what you can see here in the yellow, separating from the fat and the oil. And so when we think about fat grafting, we gotta think about a number of different things. And one of the most important things we wanna think about is retention. How much of the fat we put in there stays in there? Cuz the answer is not 100%. And really, depending on where we put it, that percentage can drop precipitously to only 10 to 15%. And what affects retention? And there's a number of different things that affect retention. The first is tumescence, what you're using and how much of it you're using. So if you have a lot of lidocaine in your tumescent, and you transfer that lidocaine with your fat into whatever site you're going to, that will actually kill off some of the adipocytes, and your retention volume will go down. Your harvest technique, if you use a lot of negative pressure. So if you're using ultrasound-assisted liposuction or power-assisted liposuction with a lot of negative pressure, you're gonna hurt those adipocytes, and your volume retention is gonna go down. If you're using a very tiny cannula when you're harvesting the fat, you're breaking the fat cells as they're coming in. Again, your retention volume's gonna go down. How you process the cells, and now if you read fat grafting papers, you're gonna realize that every single person processes them very differently. And that is one reason it's really hard at this point in fat grafting science to compare between results. And then your recipient bed. If you go into a super scarred recipient bed that doesn't have a lot of vascularity, your retention volume is gonna go down. Whereas if you fat graft into a nice soft area, your volume is gonna be much higher. So it's really about all these factors. We put those together to decide how much fat is gonna stay, and how much we need to potentially over graft. So let's talk about stem cells. Stem cells are magic, right? I don't think we have the answer to the magic, where the magic comes from. But I will tell you, it's not just the stem cells themselves. So adipose derived stem cells literally means fat derived stem cells. We love them because they're easy, we all have plenty of fat. They reside in the perivascular compartments of the adipose stroma. So they're around the fat, but not in the fat. And they're isolated through collagenase digestion and red blood cell lysis if you wanna just, if you're in the lab and you wanna just get out the ADSCs. And then within your stromovascular fraction, that's what you're gonna get if you process with collagenase and red blood cell lysis. You won't just have ASCs, you'll also have pericytes and endothelial progenitor cells. And so this is what that sort of looks like. You can see this is from a publication by Fontes et al. And this is how your fat sort of separates here. You have your oil and debris at the top, your adipose tissue in the middle, that's the fat. And then your aqueous layer, and then if you spin this down, that's where you're gonna get your stromovascular fraction. And this is what some people use to augment the fat, really isolating this factor by itself. And mixing that with just your adipose tissue, or depending on your indications, putting that in by itself. So what about all these growth factors? What are they doing, and why are they important? Why can't we just put fat wherever we're going? And this lays out what these four factors do. So the first one, basic fibroblast growth factor, that enhances the migration and proliferation of endothelial cells and enhances adipocyte survival. It's anti-apoptotic, so it's gonna help your fat cells live. And it's pro-mitotic, so it's gonna help them divide. Then you have insulin-like growth factor, again, increasing adipocyte survival. VEGF, that's vascular endothelial growth factor, that's what's gonna lead to your pro-angiogenic factors. And help with endothelial cell survival and migration. So if you just have fat by itself without these growth factors, you're not gonna get the survival that you want. Again, your retention is gonna go down. So where are these growth factors? I showed you all those layers. And you're thinking, well, if I dump off the oil layer, am I dumping off all my growth factors? Or if I spin this down, am I losing all my growth factors? And this paper by Balua et al shows us where those growth factors are, so they did the separation. And here you can see those four different growth factors that I just discussed, and then you can see how they isolated them. They have the native sample on the left, in the bottom left corner there. And then they centrifuge them, and it shows you where all the growth factors are. And I think it's really important to know that the growth factors are in all the levels. But they are in that purified fat level, which is really important cuz that's what most of us are injecting if we're not centrifuging down your fat. So let's put that all together. How are we gonna walk out of here knowing our basic science? One, small volumes. If you take, for the hand, if you take 100 cc's and you put it in a finger, first of all, you're gonna have a lot of problems. But second of all, that's not gonna survive. So you want small volumes in small areas. You want low suction pressure. I personally do, because I'm doing small volumes, I do all my liposuction by hand for this indication. And there's really no ideal preparation process. When we look across articles, we can't compare the preparation process enough in 2022 to say, this is how you should do it. So really, dealer's choice at this point looks like a lot of different ways are successful, and some of my colleagues are gonna talk about that preparation process. And then mature adipocytes alone are not enough. So in that fat layer, the fat cells themselves are not enough. You've got your growth factors, and you've got your stem cells that are working together with the fat to help with fat survival, and to help with retention, and potentially any of the regenerative processes that go on with fat grafting. Thank you. All right. Yes. So we're gonna go a tiny bit out of order here because we're just waiting on Dr. Baltzer. Looks like her files are working, but not here yet. This is Dr. Kohlberg, and he's gonna talk to us about the indications for fat grafting. So we're gonna go a tiny bit out of order here because we're just waiting on Dr. Baltzer. Looks like her files are working, but not here yet. This is Dr. Kohlberg, and he's gonna talk to us about the indications for fat grafting. Well it's either opening 20 times or not opening at all. We'll give it a second. Yeah. Oh, there's Heather. Let me see if I can open hers. There we go. I think there's just a long delay. Okay. Dr. Baltzer. Thank you. Oh, am I first? Okay. Good morning, everyone. Sorry about that delay. I've been having some technical issues all week. So I'm Heather Baltzer. I'm a hand surgeon at the University of Toronto, and today I'll be talking about fat grafting and specifically focusing on harvesting techniques, safety, and complications. So I have no disclosures to make. So the way I thought about this talk is I wanted to look at it through the lens of someone who uses fat grafting for small volume lipofilling in the upper extremity, which is what I use it for in my practice. I use it for grafting into the CMC joint. I use it for lipofilling around scars and nerves. If you're interested in learning how to do large volume lipofilling like Brazilian butt lifts, you need to go to a different room because we're not going to be focusing on that today. So we're just going to talk about techniques that you can do to avoid complications and some of the sort of generally accepted approaches to promote safety. So the first thing you want to think about is selecting your donor site. So where are you going to harvest the fat from? And so there are three general places that we would think to go to first. The abdomen, which is the site that I use in most of my patients. It's pretty easy to access. They're supine already. Their arm's on an arm table. So that's usually what I use. You can also use the flank or the thigh. And there have been some animal and human studies that haven't shown any difference in cell viability or residual volume after adipose grafting from any of these three sites. So it really doesn't seem to make a difference in terms of the residual fat. You have to think about it though in terms of many different considerations. So where is the fat located? So generally people do have fat sort of in that peri-umbilical region, so it's pretty easy to access that. If they don't, then you can go to the flank or the thigh. And you can really just kind of base it on what your experience is and what you've seen as well. For a safety perspective though, you really need to think about whether or not they've had previous abdominal surgery. Take a thorough history about that and examine them for hernias, and that's really critical. If they have a small umbilical hernia like the person on the bottom, you can work around that and still use that abdominal fat safely as long as you're sure they don't have any other hernias. But if they have a very large ventral hernia or incisional hernia like the picture on the top, then that's not an area that you want to be going with a liposuction cannula. The main thing you want to avoid with this is perforating a viscous or a large vessel. And also if they've had a hernia reconstruction, there will be a ton of scarring in that area, and there's mesh, and again, that's the thing that you don't want to get involved with. Sometimes they have scars on their abdomen from other things like skin lesion excisions or a smaller operation, and if there's no hernia or anything unsafe in that region, sometimes I'll just use that. Rather than going around the umbilicus to make my stabs to harvest the fat, I'll harvest it just using a scar that they already have existing. So contraindications would be someone who's very unwell, serious medical comorbidity, and you'd have to balance the benefits of doing small volume lipofilling in their upper extremity versus what's going on with their general health. If they don't have adequate adipose donor sites, they won't really have a lot to offer. And then thinking about all the things that I talked about with scarring and previous surgery. So in general, when we prepare the donor site where we're going to harvest the fat, we use something called tumescent anesthesia. And way back when liposuction started, this wasn't generally done. It was called dry anesthesia where you have no tumescent. And then there are these categories of tumescence which really apply more to sort of like larger volume liposuction, but I'll just kind of go over them. So with wet anesthesia or wet tumescence, you're putting in about 200 to 300 cc's in the area that you'd be harvesting from. For super wet, it's about one time what you anticipate aspirating. And for tumescent, you're infiltrating until it sort of is quite targeted uniformly. And that's generally what's, for liposuction, what's recommended because it's the safest for the patient. So the pros of using tumescent anesthesia is that you have reduced blood loss and bruising because generally the tumescence has some epinephrine in it. It has improved anesthesia, so the tumescence has lidocaine in it. So that's something that will help with the intra-op discomfort that they experience and then the post-op pain that they experience. And then it also makes it easier to remove the fat because it's like hydro-dissecting that soft tissue. You're infiltrating a bunch of fluid, so it just comes out more easily as you're harvesting. So that makes the work a little bit easier for you as the surgeon. The theoretical cons are lidocaine and epinephrine toxicity and fluid overload. And for the purpose of this course, the amount of tumescence that you'd be putting into someone, you wouldn't get close to reaching those thresholds. You're putting in about 300 cc's of tumescence into a small area. So what I use for a tumescence solution, I keep it really simple. I just use one liter of ringer's lactate and mix in 20 milliliters of lidocaine 1% with epinephrine. And that's how I do it. There are lots of different formulas for a tumescence solution, but this just gets the pain control and also has some hemostatic component as well. So this is just a little video, hopefully it works, of infiltrating the tumescence. So this is for the abdomen. So where I'm going to make my stab incisions to harvest the fat, I just infiltrate a bit of 1% lidocaine first. And then I use a 60 cc syringe with my tumescence solution and an 18 gauge spinal needle. And I just fan out in the area where I'm planning to harvest the fat. This person doesn't have a lot of fat, so it doesn't take a lot of tumescence, but you can see how it's sort of bubbling up and getting that sort of turgid appearance. So that's what you want to do. You want the soft tissue to be quite firm after you've finished infiltrating your tumescence solution. So in someone like this person, I probably infiltrate about 200 cc's or 300 cc's in that whole area in their abdomen because they're quite thin. But that will just depend on the amount of adipose tissue that the person has and the size of the area that you're infiltrating. There has been some question about whether there's an impact on graft take and viability based on having epinephrine and lidocaine there. And there doesn't seem to be any evidence in animal models that this demonstrates that there's any impact. And so the consensus is using tumescence solution at the time of fat graft harvest does not have a detrimental effect on fat cell viability. So in terms of methods of harvesting, there's just sort of hand-powered suction using a syringe and syringe-based suction aspiration, or using a suction-assisted or ultrasound-assisted lipectomy. My preference is just to use syringe aspiration. What that involves is using a 10 cc syringe and then you have a 3 to 4 millimeter bucket handle cannula. And I put it out to suction. I use a little red needle tip. I'll show a video of what I do that holds it out to suction so you can save your own CMCs. You're not having to hold it out. And because you're not harvesting a lot, it's not a huge amount of work. Because you're not using power-assisted or ultrasound-assisted liposuction, it can be a little bit more work for the surgeon. But because it's small volume, it's not really that big a deal. I like it because it's minimal equipment, keeps it simple. If you're starting this out in your practice, you don't have to purchase large, expensive equipment as you would with suction or ultrasound-assisted lipectomy. And the cannula is smaller, generally. I think you can get smaller cannulas for the suction-assisted. But the good thing about having a small cannula is that you have more control over it. You know where it is all the time so that we avoid any perforations, which we definitely don't want to happen. So with suction-assisted lipectomy, it's something that's a little bit easier in terms of harvesting because it has power that helps suck the fat out. Or the ultrasound actually kind of breaks up the fat a little bit to help get that out. But it has more disposables, and it's more expensive because you have to buy the system to go along with it. And then there's a risk of burning the skin when you have ultrasound-assisted lipectomy as well. So in general, some of the studies that have looked at different types of harvest techniques, it's shown that with suction-assisted lipectomy or ultrasound-assisted lipectomy, there's poorer cell viability than if you just do it manually with a syringe. And so if we're going for having good cell viability for a graft take, then that's something that you want to do. So that's why I use this in my practice, just the hand-held syringe aspiration. There are different processing methods. I'm not going to get too much into these because I think Paige Fox is going to talk about this more. But really, the whole goal of the processing techniques is to try and get a higher concentration of stromal vascular fraction and the adipose-derived stem cells. And so there are different methods, including centrifugation, gravity separation, washing, filtration, and mechanical separations. And from the studies that I looked at, there don't seem to be significant differences in retention. But I think this is an area that people are investigating this quite keenly to try and understand how they can improve the fraction of stromal vascular cells as well as the ASC that they have in their injections. So when I do this, I do this either in the main OR or in a procedure room where I have access to conscious sedation. Like I said, I usually use the lower abdomen. I'll infiltrate it with a tumescent solution containing the lidocaine. And because I do this mainly for CMC injections into the thumb, I only need to harvest a small volume, like 10 to 15 milliliters of adipose tissue. And I use a syringe suction with a 3-millimeter bucket-handled cannula. I process it using gravity separation for about 10 minutes and then mechanical separation with a three-way stopcock just to kind of break up the clumps of fat. So here's a video of what I do, making two small incisions on either side of the umbilicus and just making sure to—he has a bit of an umbilical hernia, so avoiding that. There's the blend tip needle that I use to help create suction so that I don't have to keep suction myself the whole time. And then when you insert your cannula, you want to make sure that you're doing this so that you're parallel to your rectus fascia. You just want to keep it parallel at all times. You do not want to penetrate the rectus fascia. And so here I am putting it on suction, using that blend tip to hold me into suction. And then as I start to advance, I pick up the fat and I'm always knowing where that cannula is going. Between my fingers, it's not going anywhere else, so I'm in control of that cannula. Or you can put your hand flat on the abdomen and then you feel the cannula running parallel to your hand and parallel to the rectus fascia so you know where it is at all times. So that's a safe way to do it. And then I let it separate out and then here's some of the tumescent solution that you get rid of and then you have the fat that's there ready for injection. And then like I said, I just pass it a few times through a three-way stopcock just to kind of break it up into smaller globules. One thing that I didn't do in that video, which I normally do, is I pass a number of times without being on suction and that just helps to kind of break things up a little bit more before I go on suction to make it a little bit easier for harvesting the fat. I just forgot that day. I was so focused on making the video. So in terms of complications for small volume fat harvest, I'll talk about the ones that are possible and then there's some theoretical ones and they apply more to large volume liposuction. So for the possible ones that are more minor, you can have incision site infections, temporary hypoesthesia, some hemocederin deposits where they have bruising, and if you're using ultrasound lipectomy, then that can also lead to thermal injury of the skin. The major one that we always want to avoid, and that's why you want to ensure that you're selecting your patient appropriately, your harvest site, is to avoid having any perforation of a major organ or vessel. The theoretical risks don't necessarily apply. Usually we're harvesting so little volume that you won't really have any symmetry, but I guess in theory it can happen. You can have a seroma form, but again, it's such a small volume liposuction that you're doing that I think it's quite unlikely. You're not injecting usually enough tumescence to cause a fluid imbalance and then the other things are really like a fat embolism syndrome or a massive infection, lidocaine toxicity, and DIC. Those are really associated with larger volume liposuction. So again, probably pretty rare in the setting of what we would use it for in the upper extremity. So in conclusion, I think that this is a pretty straightforward procedure and I think it's very safe if you ensure that you take the right steps to select your patients and your donor site appropriately. If you don't have experience with this and you're interested in adding this to your toolkit as a surgeon, then just ask a colleague if you can hang out for a case and watch them do it. I think it's a pretty straightforward technique to pick up. I think this is something that as we sort of understand the science a little bit more and why this can be helpful in various conditions in the upper extremity, it's going to become more and more common, so a good skill to add to your toolkit. So thanks very much for your time and I'll look forward to seeing everyone in Toronto next year. Have you ever done this just in the office? No, I haven't. I do it, I like to give them sedation because it's like, it can be quite uncomfortable when you harvest the fat. I think some people do, but that's just not my practice. Canadians maybe aren't tough enough to handle that, I'm not sure. Hmm Oh, here we go. Let's see. Hold on. Hold on. OK, great. OK. So I'm David Kolber. I'm the Chief of Hand Service at the Cedars-Sinai Medical Center. And I'm just going to go over some of the indications and then of fat grafting. And then we'll have a little question and answer session. I think it's important to remember, like when we're doing fat grafting, that you're doing small volumes that will be interesting to see how much we all think the fat is, how much fat retention you get. I typically think in my mind that you get maybe 50% or 60% of the fat will stay. And that's maybe optimistic in some points. But it depends on how much you're injecting in the vascular area that you're going to be injecting into. So what I'm going to talk about is the indications for scar contractures, tenolysis, neurolysis, Dubertin's disease, basal joint arthritis, wound and elbow arthroscopy, rejuvenation, and gender affirmation, some things that we've written about. This is a recent article that we just had published in PRS about autologous fat grafting in the upper extremity. I wanted to thank my fellow Peter Deptula and Tennyson Block and Kylie Tauby, my physician assistant, for helping to put together all these cases. So thank you, because it's a team effort. And so we're just going to go through some cases. And really, these cases are based on this paper that we just wrote. So what's so great about fat for scar revision and contracture release? Well, I think it improves skin quality, it reduces adhesions, and it has some regenerative properties to the soft tissue. I'm not the first person to think this. It's been used in different types of settings as far as burn contractures and wounds. I'm just going to show you a couple of case examples. So this is a person who had soft tissue injury to the dorsum of their hand. You can see right over here, there's a scar contracture and adherence. And this is something that you could just do fairly easily. What's not shown in the video, though, it's here. We do pre-tunneling before and release the scar contracture. And then just by injecting the fat over the scar contracture, it fills out that dead space. It's important to kind of, like when you inject, to kind of inject in line so it doesn't clump up. So you'll see in some other videos, I'm injecting and I'm pulling back, so creating lines. So you don't want to have clumped up fat. Then here you could see, really, that contour deformity is completely released. You're releasing the adhesions in that area and you don't have that big divot. And that's just done through two small, tiny incisions where you could do cross-tunneling and release that contracture. And you use a blunt cannula to do it, and then you inject with a blunt cannula. So this, I think, shows, really, the power of stem cells or fat cells, adipocytes. So this is a guy who presented to me. Let's go back here. A year after he'd been, he was at Burning Man and he fell in the fire. And here he's got a very severely burned hand. That's after being at a burn unit and being skin grafted. And he was like, is this all? And I said, no, we released some contractures in his web spaces here, in his first web space. But more importantly, we fat grafted the whole dorsum of his hand. And just after a few years, you could see just the difference of skin quality, of what he's able to do. Pretty impressive. And I think that shows the power of the healing that you can get with these adipocytes. And let me just go back to this one area here. You could even see, like we fat grafted, we had a scar up here. And we just put some fat underneath that and really the scar disappeared. So tenolysis is another great use for it. And it can be applied to both the flexion extensors. It reduces adhesions of the tendons. I think it facilitates tendon gliding. And it's got the regenerative properties. So here's someone with a flexion contracture here. And we're injecting fat after releasing the flexion contracture. And I'll show you a. So this is someone who has, after a flexor tendon repair, they're really adhesed. This happens to all of us. You do a flexor tendon repair and they're just totally stuck. They have good passive motion. But their active motion's not great. And now you're going to operate on them. And what are you going to do differently aside? And so I think that tendon fat grafting in these cases to prevent adhesion. So this is during the surgery. But little vesselips around the nerve. We've released all the soft tissue and the contracture in this area. Let's see, keep that going. And we're really make sure that the tendon's completely released. But what are you going to do to prevent scarring again? I know you want to get them in early motion. But still, there's going to be scar tissue around the tendon. So this is like fat grafting after we close the wound. And we're putting fat all along the tendon sheath. And remember, you do want to use small volumes. You want to put enough in that you'll make a difference. But you don't want to overfill where the finger starts turning white. So there's a very fine line of how much to put in. It's usually a little more than you think. But you kind of feel like the tension in the wound. I like to do these with the patient awake to make sure that we've done the full release. So we do it under anesthesia. But we wake them up at the end to make sure that they have full motion and can bend their finger. And you also want to not have a tourniquet up while you're fat grafting. I tend to, after I release everything, make sure that the tourniquet's down. So then when you're injecting, you get a sense of how tight it is. And you don't want to make it so tight where you start creating ischemia. Remember that part of this, it works because you have to have good blood supply to the fat. But if you put too much in, then you could create a problem. And let's see. And then this is the patient like a few weeks later. Wound's completely healed. They have much better range of motion. Not worried about a recurrence anymore of deflection contracture. The skin heals nicely. And everyone's happy. But I think the important components to that is not overfilling, but getting enough in there to make a difference. Another indication is nerve decompressions. What's really been written about a lot is that peripheral nerve surgery, that both fat and there's some articles about fat and PRP, that the PRP preserves the adipocytes and helps them survive better. But the idea is that a psychosomal mind of its own protects the adipocytes from the adipocytes. So it protects the nerve. It facilitates a gliding plane. It has some anti-inflammatory and angiogenic properties. It supports nerve healing. There's a lot of basic science out there talking about this, how that it helps nerves improve their wound healing. And then you also do, in some cases, you're doing volume restoration for contoured deformities. But the most important part, I think, is nerve gliding and maybe nerve regeneration. So this is a case of a lady who came to me who previously had a dequiverent release elsewhere, subluxating her first extensor compartment. But more importantly, she had all the scar tissue around her radial nerve. She had a lot of neuropathic pain. So we released her. And you could see all the scar tissue around her radial nerve. The vestibules around the radial nerve. Here's her first extensor compartment released. And then here, you could see right here, we've released all the soft tissue. The radial nerve is completely released. And then what I like to do is we close the wound. We put the cannula in after you close everything. And then just kind of putting fat over that soft tissue defect. After you've released all the soft tissue, you like to close the wound. The tourniquet's down. And then you're grafting over the nerve. And then this is the patient a few, like a month or two. You could see how the soft tissue looks really good. It's nice and healthy. She's moving the wrist really well. There's no scar contracture, especially in this area. Around the first eccentric compartment, you get a lot of scar adherence to the nerve. And divots and contra deformities, no matter what type of incision you make. I think we've all tried different types of incisions for the first extensor compartment. And no matter what you do, you can get scarring around the radial sensory nerve. So in some cases, I even put fat in just after a primary release, just to prevent that scar adherence around that nerve, which can be painful for such a small operation. But you can really see the difference in the skin quality here from that. So this is a patient with an ulnar nerve. Pretty bad ulnar nerve contracture. You can see all the first dorsal interosseous wasting. And you can see the ulnar nerve after a release. So you can see a very tight area here, and pretty bad nerve compression as far as. So for the ulnar nerve here, we release it and then close it. And then you kind of pre-tunnel, so you have your cannula right over the nerve, and then inject the fat. And then what you can do on these patients, which makes them very happy, is for the first dorsal interosseous wasting, you could kind of fill that whole compartment up with fat. So it's not going to be a functional muscle, but it definitely looks cosmetically better. And they're a lot happier not having the wasting in their hand. And so you could achieve two things at once. One, help with the nerve regeneration and prevent additional scarring around the nerve. And secondly, help with the cosmesis of the hand. This is recurrent carpal tunnel syndrome. We could do this. I'm going to show you two different techniques of how to deal with someone who has scarring around their median nerve. One is releasing it endoscopically, which in some cases, I think it's in the right patient. It's a good way of doing it. So here's the endoscope, like the Stratus endoscope here. And we've released the scar tissue around the median nerve. We identified the median nerve. And then we're kind of injecting the fat all around the median nerve. And you could see it on the video going in. And then this is what it looks like from the outside, injecting fat. How much do you inject? It's usually between, in this area, a small compartment, maybe 5 to 10 cc's. But it depends on the tightness that you're in, the skin volume that you're putting in. You have to remember that not all of it is going to stay. So you always want to feel like you're overfilling a little bit because some of the fat's going to dissipate. And you want to go back at both sides of the nerve. This is a little more of an aggressive. This is a lady who had a nerve injury many years ago. She, over the years, developed a really bad tunnel sign in that area. She couldn't touch it. It was super painful. And so it's one thing. We released the nerve over here. And you could see she had this huge neuroma there. And so we basically just debulked it. You don't want to resect it because I think that causes a lot more, looking for a lot more problems. And here's just releasing all the scar tissue around the nerve. I'm just pointing out the motor branch, the sensory branch, completely dissected out the entire neuroma and debulked the whole thing where she was having a lot of pain. You can see the more distal part of the nerve there. This is all the scar tissue we removed around the nerve. Here's the fat that we had harvested. We closed the wound. And I usually like to close the wound with the, in this kind of case, I keep the cannula in. And then I close the wound over the cannula so I know where my cannula is when I'm injecting. So it's not blind and you're not just going back and forth. So you have a sense of you're injecting over the nerve. And you can see how I'm pulling back as I'm injecting. Over that area. And I don't take the cannula out in this case because you really want to, you don't want to be jabbing it in blindly when you have the nerve so superficial there. And you're really just creating a space between the nerve and the soft tissue. So there's no more adherence to the nerve. And you have something between your skin and the nerve itself. And this patient did very well. It relieved all of her pain and symptoms around the Tinel sign. And neurologically, she did pretty well. This is another recurrent carpal tunnel. You can see the compression right here. And it was scarred down right here. So very similar. We have the, we close the wound with the cannula in place. And then you're injecting over the nerve so you know where it is at all times. So you're not injecting or pushing in on it. And you just have to feel the soft tissue because you want to inject enough that it makes a difference again. But you don't want it so it's feeling so tight. Because if you inject too much, then you could be impeding the blood supply to the adipocytes and doing damage. So Dubutrin's disease. I see Roger Corey's in the audience. So I'm glad I pulled his paper here. So Roger's been doing this for a long time. He's written about it. Several years ago, we did at the Hansa side, we had a symposium and he was there. And he's been talking about using fat for Dubutrin's disease for a while. He does like a needle release and then does backfilling of the fat. I don't know if he's still doing that or if he's changed it. But I think it's really great for Dubutrin's disease. It's got a lot of potential prevent maybe recurrence of Dubutrin's disease because you're filling that whole area up with fat to maybe prevent it from recurring. And it separates any of the dermis from the residual cords. And you're basically putting in something that's filling a soft tissue defect after you have removed the disease. So instead of scar tissue forming in the palm, you have fat in the palm. So this is someone with recurrent Dubutrin's disease. They are pretty frustrated. They can't fully extend their hand. They've already had a fasciectomy by someone else. And they're just not happy with their motion. And it recurred pretty quickly. So I think this was a good case of seeing if we could help them with some fat grafting and prevent that recurrence. So here you could see all the scar tissue around the whole area. In this case, I felt you just have to remove everything. So we've removed all the scar tissue in the Dubutrin's disease. There's the vessel loops around all the nerves. It was like chiseling out the vessels from all the scar tissue, which happened pretty quickly. And then I like to wake the patients up and make sure that we've released them. So this is first me just fat grafting them. You could see I put a Pemrose drain in. There's a lot of dead space. So in some cases where I feel like there's a huge dead space, I don't want blood to accumulate underneath those flaps or fluid. I just want the fat there. So sometimes I'll inject fat, but also put a Pemrose drain just to allow any other oozing or egress out of the whole thing. And then here you could see them on the table completely being able to make a fist, fully extend their hand. And we're able to lay the hand flat down so the tabletop test, now they could fully extend their fingers. MCP joints are fully flexible. And they can make a fist, which they couldn't do before. One more. This is really more along the lines of what Roger likes to do, basically, almost a small incision for a percutaneous release of a little contracture here. And then backfilling it with fat. This one I didn't put a drain in, but you just really want to prevent further. Once you release it, there's a dead space. I think this patient also had a trigger finger on top of Dubertin's disease. So we released that endoscopically. And then just made that incision in the base of the proximal phalanx and fat grafted them. And you could see them after the surgery. They're nice and straight. There's like a little puckering from the fat there. That usually goes away. But I found that this is very helpful. And since I've been fat grafting the Dubertin's patients, I've noticed there's really less of a recurrence. And they've maintained their motion with really less scar contracture than I previously had. So this is something that we've been doing a lot of lately. And I think we're all looking at the fact that fat really helps with arthritis. This is a little presentation we gave last year about using it in the basilar joint. What I do is I like to use a nanoscope and do a synovectomy. And then I'll do a CT scan. And do a synovectomy and then inject the fat. If you're interested in the nanoscope, there's a video that we made for Arthrex about using the nanoscope for the basilar joint. But there are people in their papers that are just injecting it into the joint without doing any debridement and having relief of pain with just fat alone into the joint. And I think it helps regenerative properties of that. And I think for the basilar joint, I'm more into right now doing the nanoscope. But I can see just injecting fat into the basilar joint around the soft tissue. And patients get relief. And I think it's more regenerative and less destructive than necessarily giving a cortisone injection. So this is someone with scaphotrapezial arthritis. That's pretty severe right here. And this is kind of the setup for it to use the nanoscope. And here we're in with the nanoscope. And that's the top you're seeing here. That's the trapezoid and trapezium. And the base is the scaphoid, the head of the scaphoid. It's pretty gnarly right here with big chondral defects. And in my mind, I'm thinking, OK, how is this going to really relieve their pain? Does this really work? And then after you do the synovectomy with the shaver, then we just inject fat into that area. And you convert it from a wet arthroscopy to dry arthroscopy. So you suck out all the fluid. And then you're injecting fat into the whole joint space. You close all your portals before you inject the fat, because it will run out of the portals. And we're now looking at our numbers. But we've done up to 70 three-year follow-up for basilar joint and scaphoid trapezoid arthritis. I haven't had to operate on anybody for recurrent symptoms. So we're ultimately going to publish that. And I'm surprised, because on patients like this one that I did, I thought for sure this wouldn't relieve their pain. But they wanted to try it. We also use it for radiocarpal arthritis and wrist arthroscopy. So this is kind of the setup here. And here you can see a lot of radiocarpal arthritis here, chondral defects in the radius. We debrided it. They had some scapholunate and TFCC tearing. So we kind of debrided that whole thing. And then here you can see, after we've debrided everything, we have converted to dry arthroscopy. I usually do it wet, just for the debridement part. And if we're going to coblate or anything, then convert it to dry. And then once you do that, you can see the chondral defects here. And then you're injecting the fat into the radiocarpal joint. And this is kind of the setup that we have here of the injection. So they're in a traction tower. You're typically, you turn the tourniquet off. And then you can see the fat going in right here. Here's another case, ulnar impaction syndrome, large TFCC defect. We've kind of burred down the head of the ulna right there that was impacting on the lunate. You can see a big chondral defect up here around the lunate. We've coblated that whole area and debrided it with the shaver. And then now you're leaving a big hole there. And like, well, what else can you do? Because it always felt to me like kind of not complete, just leaving this whole scenario here without doing anything else to create a cushion or something. So now we're injecting fat around that whole chondral defect in a big TFCC tear. Another great indication is elbow arthroscopy. This is a guy who's got really bad ulnar nerve compression, cervical spine compression. He's got a lot of muscle wasting here. He's a fashion designer, so he doesn't like this. And then he has a lot of arthritis in his elbow. So this is his elbow with the big chondral defects being scoped by my associate, Dr. Tsai. And after this is all getting debrided, you can see all the kind of loose bodies in the elbow. And then after we debride all of the whole elbow and feel comfortable with the debridement, then we inject fat into the elbow. And this is you convert from, again, dry to wet to dry, and then inject the fat into the elbow, close all the portals. So you just have one little portal for the fat. And we've had very good outcomes once we've started doing that with the elbow. So I'm pretty impressive. And then here you could see him post-operatively. We injected all around those contral deformities as well. So he's happy because he doesn't have big divots in his arm anymore and has less elbow pain. So I've written about this in the past. It's been in our hand journal. But I think this is something that, as hand surgeons, we should all be cognizant of because we're the experts in hand. And that is rejuvenation. So as we age, there's atrophy of the dermis. And the fat in our hand, you could get prominent dorsal veins. There are some people who think you should take out the veins. I really think that's a bad idea. I think what you want to do is cover the veins with fat. When you age, you get prominent extensor tendons. You see the skin, it gets kind of thin. So here is a patient with soft tissue atrophy. Here, this is from a cortisone injection. And this is the power of fat grafting here. So you pre-tunnel over this area. And then you inject the fat here. And then you could see them just about six months later. And the skin looks rejuvenated. They don't have a big defect. It's all filled out. And the skin looks a lot healthier. This is another case of someone who had previous cortisone injections and basilar joint pain. So we did a basilar joint arthroplasty on her. And then we injected fat all around the area where there's the soft tissue defect. And here you could see us doing that here. And you could see how well the skin looks afterwards. So that's probably about six months afterwards. All that pigmentation is gone. Pretty impressive. And then this is just the aesthetics of the hand. So if you're gonna do fat grafting for aesthetics, I like to mark out the veins. You don't use a tourniquet, you wanna see everything. The worst thing that you could do is get bleeding after you're injecting fat. Fat and blood is a bad combination. So you really want to, that sets you up for infection. The fat can get hard. So you really want a good vascular plane. So what you do is you pre-tunnel around this area, avoiding all the veins, so I'll mark them. You don't wanna put a tourniquet up. You wanna do it with a tourniquet down so you could see where your veins are. And you just wanna slide your cannula over the veins, not into the veins, and then kinda cover up that whole area right here. So you can see you've gotten rid of all the dorsal veins. Then post-operatively, I'll put them in a little, just co-bound for the swelling that they can get. And then you can see here, all the prominent veins are gone. You really can't see the extensor tendons. And over time, the hand's gonna look a lot younger. And they're happy that they don't see their tendons or their veins. This is an article that we wrote a little while ago about gender affirmation in the hand. Really, the key is to, you wanna make the hand, especially male to female, to make it look slimmer, less bulkier, less rough. So the things that you can do are fat grafting over that area to make the joints look less severe. And then also, in some cases where they have arthritis, get rid of that bulkiness around the big osteophytes. And sometimes you end up fusing their joints for the cosmetic reason, and they're having pain. I would never fuse a joint just for cosmesis. But if they have pain and they want a thinner-looking joint, especially for gender affirmation, that can be very helpful. And then you could see here, you could see all the prominent extensors here, and how bulky the distal phalanxes are. And then when you're fusing the joint and putting some fat in, it looks just a little thinner. They're minimal things, but it makes them happy and feel that they're moving in the right direction. So, you know, this is, I think that what I've learned is I think fat can be your friend. I think it could be very helpful for a multitude of surgeries that we all do, and help with some complications of scar adherence and wound healing issues. So thank you very much. Does anybody have any questions for either of us? Okay, I guess we'll just, well, Roger. Congratulations. Very nice sum up and nice overview. Really impressed with your work with the arthroscope. I think it may be the future. I've been grafting CMC joints for a long time, and the early stages, they do well, but the advanced stage where there's no joint space, what I've been doing is putting a small distractor for a couple of weeks. And you put a few tips. I've seen you all inject with 10cc syringes. That's bad for your CMC joint. Plus you're not precise either. So I inject with three CC syringes. The other trick also is use a curved cannula. That way you have better chance of going around there, multiple passes. But I agree with everything you guys said, except for the Dupuytren, I don't make no incision. You mesh expand the whole thing with multiple needles. It works just as well. They don't have stitch, and they go back to using the hand earlier. But it's a beautiful presentation. I love the joints with the arthroscope. I wanna try that. Okay. Okay, so you do your needle at the rod. Yeah. You use a larger tool. Are you doing the test, and you do not do the needle at the rod? Okay, so the needle at the rod, I mean, we do, is different from the standard LeMessurier technique and the one my friend Charlie Eaton does. They do a dermal anesthesia, and their safety for not damaging the nerve is if the patient feels something, they stop at that point. If the patient has numbness in that hand, if they give them a block, a nerve block, they don't do, they abort the procedure. We do it totally different. We do it in the operating room with tourniquet exsanguination. Patient awake, we, by the way, we stopped using anesthesia for our hand cases. We'll get rid of those guys. They just get in your way, they slow you down. Literally, I mean, we give our own block, including supraclaviculars. We know the anatomy better than they do. But, and yeah, so, and another point also, by the way, I think if you exsanguinate the hand tightly, you won't get into the veins. You're right, blood and fat don't mix. There's a big problem there. But I do, I inject the fat with the hand tightly exsanguinated, and you never puncture a vein that's been emptied with a blunt cannula. So what I do, I put a, so the difference, the safety technique for us is I do it in the operating room, hand very exsanguinated, so you don't damage your blood vessel, and then I use the old-fashioned lead hand. They're hard to get. I saw you guys using aluminum hands. These are wimpy. Yeah, those old-hand lead hands really broken. You need to get the old lead hand. Supposedly, it's toxic bullshit. I mean, so I've grown up using lead hand for 40 years. So you put, and that puts the contracture on the tension, and then you mesh it, you mesh the tissues just like you mesh a skin graft, and it opens up. By the way, I close wounds like that, scalp wounds. I just put on the tension, mesh it, and just bring together. So there's a, meshing is a very nice technique. The beauty here is that the needle will only cut what's under tension. You won't be cutting a nerve. A virgin nerve is not under tension here. So by doing this, you shred, and you create a recipient space for the fat. Thank you. Any other questions? Yes. In the United States, is there any insurance issues approval for doing the fat grafting? Yeah, I think there are some issues. I haven't had any personally. We've got reimbursed for fat grafting. I don't know, have you found that in Toronto? Yeah, I mean, it's totally different. We don't really have a code for it. So either I'll charge the patient, and they pay for that part of the operation separately, or sometimes I'll incorporate it with another code, creative billing. So for like. Well, that's all cash. They're paying up front for that, yeah. Yes. So, if you have a good vascular bed, and you've got good quality fat, which is something that we didn't talk too much about, but as we age, our fat atrophy, so younger people's fat is probably better, as far as for injecting and survivability of adipocytes, but I always think I over-inject that area, and I think about 40 to 60% of the fat will stay permanently, so oftentimes you don't have to re-inject them, and if you do, it's maybe a little bit, but oftentimes that's enough to make them happy. Yes? I was reading about this with scleroderma, do you want to experience that? Yes, I think it's very helpful for that, I think there's like a lot, and I've used it for scleroderma patients, you have to be extremely careful, because you can cause more damage if you over-inject, but I think that's another case where you have adgenogenic properties that help scleroderma patients, and have you had experience in scleroderma? I haven't used it in scleroderma, it's a great indication though. You have to be very careful, but in the right patient, it's helpful, I think there are people who've been writing about it, I think Neumeister has written about it, right? Yeah, and I think it's helpful. Do you go back multiple times, like you just put a really small volume? Yes, very small, this is where you're using like a 1cc syringe, and you're just going back very superficially, but it does help, and I've had some good outcomes with it, but you have to pick the right patient. So, here's the best thing I can tell you about that, okay? What convinced me that this is really something that works in a poor blood supply area is in radiated breast cancer patients. So we, it's, yes, but it's devascularized. There's no, there's no angiogenic properties in radiated tissue, right? It's fibrotic, it's terrible tissue, and you would think that if you put fat in a radiated bed, it would form a hard, fibrous, calcific area. But yet, it actually makes the radiated tissue look better. And when you're injecting around the flexor sheath, you've got a good vascular supply around the flexor sheath, which is your soft tissue. If you had devascularized skin or a poor ischemic finger, then I think that would be a bad person to inject in. But I think that you just, as long as you have a decent blood supply, fat will live. And I think the radiated model really shows that, because that's the ultimate poor blood supply bed. In the joint, so I follow my patients that have had the injection into their CMC joints, and we've done MRIs on about 15 of them, six months post-op, and there's no fat left. But it doesn't mean that it doesn't work. In some patients, it does work, and in some patients, it doesn't work. And that's, I think, an area of huge understanding of who's going to respond to this and who's not going to respond to it. And I think a lot of it has to do with, I've also started doing the synovectomy first with the fat grafting. So I think it's probably a balance of how bad their synovitis is when you're doing the fat grafting. And if you're just doing fat grafting alone and not doing a synovectomy, then if they have really, really bad synovitis, then I don't think the fat grafting will work. I think maybe that's sort of what it's tackling. I don't think it's sticking around and creating a cushion. I think it's having some other effect. Paige, did you give your talk about the... Yeah. Yeah, so probably some of the things that Paige talked about is what's happening at the level of the synovitis and the synovium, but it just depends on how bad their synovitis is. Could you reintegrate why it works in our practice? You're sort of saying, I don't know. What do you say to a patient when they're, like, we're going to go around your belly and we're going to... What do you say? Well, I do say we don't have a clear answer about why this works, but it has anti-inflammatory properties. It changes what's happening in the joint. It changes the inflammatory environment in the joint in some way. And I tell them that it doesn't work for everyone and they know that, but it's also a pretty straightforward procedure and it's pretty low harm and there are always other things you can do afterwards. But because I found with my straight up fat grafting, I was only having like 50% responders and 50% non-responders. So that's why I changed over to doing arthroscopy first and then doing the fat grafting with that. And I found that people do a lot better with that because you're getting rid of all of that. Like the synovitis is what's giving them a lot of pain, right? Also if they have big osteophytes that are problematic, you can burr those down as well. So I told, I mean, I think I told you, like, I've been doing it for three years. I've had, not one of my patients has had, have another surgery, which is surprising. I think also with the arthroscopy, you surprisingly, you see a lot of loose bodies in the CMC joint that you're removing. I think those are pain generators. So I think that's really helpful. If you have a clean joint with nothing, then maybe the, just a fat injection would be enough. But I think, I think I agree. There's no, the fat's not staying there to be a cushion. It's creating some milieu that's anti-inflammatory. then you have a face that looked at consistency over time. So it changes, in some patients it changes their synovitis, that's what we found. I mean, I think it's in a small space, so I think I'm not worried about the joint space as much. I am more worried about soft tissue, so a hematoma in your soft tissue mixed with fat is bad. A joint's really a confined area, and it's a little different.

autologous fat grafting

hand surgeries

hand procedures

anti-inflammatory properties

pro-angiogenic properties

regenerative properties

retention factors

scar contractures

tenolysis

neurolysis