Effectiveness of autologous fat grafting in adherent scars: Results obtained by a comprehensive scar evaluation protocol

We have read with great interest the article entitled “Effectiveness of Autologous Fat Grafting in Adherent Scars: Results Obtained by a Comprehensive Scar Evaluation Protocol.”1 Lipofilling has now become a fundamental procedure in the treatment of scars; in fact, many studies show the regenerative qualities of fat.2 The authors objectively evaluated the advantages obtained on scar tissue after the use of adipose tissue grafts, using both instrumental and scale assessments. In our department, we performed lipofilling in numerous cases of scars.3 Use of bioengineered tissues has entered clinical practice of the plastic surgeon. Furthermore, the quality of the tissues after reconstruction with skin grafts and dermal substitutes is certainly higher than with use of only skin grafts.4,5 Our study attempts to objectify the benefits of lipofilling after reconstruction with Integra (Integra Dermal Regeneration Template, Plainsboro, N.J.) and skin grafts and suggest a “three-step protocol,” including Integra, skin graft, and lipofilling for the treatment of loss of substance. We performed lipofilling in 20 patients previously treated with Integra and skin graft (eight men and 12 women; average age, 34.6 years), suffering from dystrophic and painful scars. The adipose tissue grafts were carried out to 3 years from the previous reconstructive procedure (range, 29.5 to 41 months). Twenty-four hours before lipofilling, all patients were evaluated with the Patient and Observer Scar Assessment Scale, a visual analogue scale, and photographic reports; also, we have performed multiple intralesional skin biopsies of scars and submitted specimens to histologic examination (i.e., Masson trichrome, hematoxylin and eosin, and munohistochemistry with CD31 antibody). The evaluations were repeated at 90 days. All of the patients signed an informed consent, and the research was conducted in accordance with the Guideline for Good Clinical Practice and the ethical principles originating in the Declaration of Helsinki. Unlike the article published by Jaspers et al., we have tried to provide an improved histologic documentation of scar outcomes after lipofilling. All cases have shown that the anatomical functional improvements have run parallel in both the objective and the subjective assessments. The most important histologic result of our preliminary study was improved vascularization. Between 90 and 120 days after lipofilling, a qualitative improvement in all cases was observed, with increased vascularization and regenerative phenomena, such as formation of new collagen and a decrease of fibrosis (Fig. 1). Skin biopsy specimens, processed with CD31 antibody, showed an improvement in vascularity. Lipofilling proved to bear valid functional and aesthetic results in the areas treated with Integra and thin dermal-epidermal grafts. Patients were satisfied with results, with great compliance. These elements are all fundamental for reaching our aim of testing the method with a wider number of cases. The histologic results of our experimental study support the clinical modifications that occurred after fat injection. These changes can be determined by the regenerative effects of the adipose tissue, as demonstrated by our histologic study. Lipofilling is therefore a versatile technique capable of enhancing the results of the reconstructions previously obtained using Integra and a thin autologous dermal-epidermal graft.