INTRODUCTION
Trauma is the leading cause of death and disability
in the first four decades of life and the third
most common cause of death over the world. Burn
trauma represents the second most common cause
of trauma-related deaths [1].
A burn is a tissue injury caused by pathological
energy. It may be chemical, thermal, electrical or
radiation. It varies from small superficial burn up
to major critical burns that threaten person's life
leaving him disable, deformed and imprisoned in
a scar [2].
145
Atrophic scars are broadly described as exhibiting
generalized cutaneous atrophy resulting in
loss of cutaneous cells in the epidermis although
appear clinically as a loss of normal dermis [3].
There are various measures for atrophic scar
treatment as ablative fractional laser therapy, nonablative
laser therapy, dermabrasion, chemical peel
therapy, surgical techniques such as subcision,
injectables and combined therapy. All of them minimize
scarring but not eliminate it completely [3].
A relatively new option for the treatment of
scar tissue is the use of autologous fat grafting.
The word “autologous fat grafting” means transferring
of the patient's own fat from an area of the
body (the donor site) to another area of the same
body (the recipient site) [4].
Autologous fat grafting has a volume increasing
effect and is thought to stimulate the neosynthesis
of collagen fibers, which therefore increases the
dermal thickness, resulting in an improvement of
skin quality [5].
It has also shown improvement of different
types of pain. The hypothesis is that mesenchymal
cells of the graft give prolonged analgesia by
changes in the microenvironment and secretion of
substances [6].
Autologous fat tissue has been widely accepted
in plastic and reconstructive surgery as an ideal
filler for augmentation of soft tissue because it is
biocompatible, versatile, natural appearing, non
immunogenic, inexpensive and easily obtainable
with low donor site morbidity [7].
The major obstacle is an unpredictable and
often low graft survival, with resorption rates
ranging from 25% to 70% of the total implanted
volume, which may be partly related to insufficient
vascularity of the transplant. Therefore, methods
to increase graft viability are required [8].
Autologous fat grafting has been introduced as
the treatment of atrophic scars and contour deformity.
It not only serves to improve contour and to
fill areas of deficiencies caused by trauma, deep
burns or surgery, but increasingly there has been
a focus on its ability to regenerate and remodel
surrounding tissues [9].
PATIENTS AND METHODS
After approval of Research Ethical Committee
of Faculty of Medicine, Fayoum University, this
prospective study was performed at Plastic Surgery
Unit, Fayoum University Hospital on 20 patients
complained of post burn atrophic scars at different
body areas in the period from February 2018 to
March 2019. Those patients were subjected to one
session of micro fat grafting conducting the same
surgical technique to all of them.
All operations were performed under general
anesthesia with the patient in the supine position.
Surgical technique:
Infiltration:
A small incision approximately 2mm in size
was made in the donor site using a number 11
blade through which a blunt multi-hole infiltration
cannula was inserted to infiltrate the tumescent
solution into the donor sites of fatty tissue removal.
The mixture injected was prepared as follows: (1cc
of adrenaline 1mg/ml were added to 1000 of normal
saline solution).
Then we waited about 10-15 minutes until the
tumescent solution penetrated into the tissue to
allow epinephrine to take full effect and provides
good hemostasis.
Fat harvesting:
Donor areas as lower abdomen and thigh areas
were chosen according to the amount of adipose
tissue.
A multi-pores blunt tipped 3mm harvesting
cannula with several side holes of 1mm in diameter
attached to a 10cc Luer-Lock syringe was used to
harvest the fat through the same incision made for
infiltration of the mixture solution.
Fat processing (refinement):
The centrifugation method was used for processing
of the harvested microfat. The aspirated fat
was allowed to centrifuge in the same 10-cc syringes
using a portable electric centrifuge at 3000
rpm for 3 minutes.
146 Vol. 44, No. 1 / Evaluation of Treatment of Post Burn Atrophic Scars
Centrifugation resulted in separation of material
and formation of three layers:
A- At the top: An oily yellow layer which was an
effect of ruptured fat cells.
B- In the middle: The adipose graft.
C- At the bottom: A red layer composed of serum,
fluid and blood products.
The first and third layers were discarded away.
The second layer was then transferred to several
1cc Luer Lock syringes using a special connector
with filter to transform the fat into micro fat. The
syringes were then attached on the Luer-lock end
to the fat injection cannula which was made ready
for injection into the recipient site.
Fat injection (placement):
A blunt tipped 1.2mm cannula with single side
hole attached to a small 1cc Luer Lock syringe
was used for fat injection.
Micro fat grafting was continued in multiple
layers until the indicated volume of fat was added
to each target area and no overcorrection was done
in any case.
Follow-up:
Follow-up of the patients occurred at 2 weeks,
1 month, 3 months and 6 months post-operative.
Results were compared by photographs all through,
together with researcher's direct clinical evaluation.
RESULTS
During the study period (from February 2018
to March 2019) twenty patients with post-burn
atrophic scars at different body areas were enrolled
in this study. 18 females (90%) and 2 male (10%).
Age ranged from 16 to 35 years with mean age
19.7 years. 60% of cases caused by scald burn (12
patients), 30% caused by flame burn (6 patients)
and 10% caused by chemical burn (2 patient). 70%
of them show scar on lower limb, 20% on head
and neck, and 10% on upper limb. In 70% of
patients the fat was harvested from lower abdomen
and 30% of them from inner thighs.
The mean duration of scar was (4.1±0.61) years
ranged between 1 and 7 years. The mean amount
of micro fat injection was (35.3±7.7) cc ranged
between 2 and 75cc. As regards scar size the mean
length of scar was (8.7±2.5) cm ranged between 2
and 30cm. and mean width was (3.7±0.79) cm
ranged between 0.5 and 9cm.
Assessment of lesions was done by physician
evaluation and by digital photos before and after
Egypt, J. Plast. Reconstr. Surg., January 2020 147
treatment. The improvement was described according
to scoring of 6 criteria (vascularity, pigmentation,
pliability, surface appearance pain and itching).
Table (1) illustrates that there was no statistical
significance difference with p-value >0.05 in the
vascularity score at post-operative follow-up periods
indicating no effect of microfat grafting on
improving vascularity score.
Table (2) illustrates that there was no statistical
significance difference with p-value >0.05 in the
pigmentation score at post-operative follow-up
periods indicating no effect of microfat grafting
on improving pigmentation score.
Table (3) illustrates that there was improvement
in the pliability score after 2 weeks and 1 month
post-operative. There was no change after followup
6 months. p-value <0.05 was statistically significant
indicating the positive effect of microfat
grafting on improving pliability score.
Table (4) illustrates that there was minimal
improvement after 2 weeks post-operative in the
surface appearance score with no change after 1
month and 6 months post-operative. No statistical
significance difference with p-value >0.05 indicating
no effect of micro fat grafting on improving
surface appearance score after 6 months postoperative.
Table (5) illustrates that there was improvement
in the degree of itching after 2 weeks and 1 month
post-operative then deterioration of response at 6
months post-operative. p-value >0.05 indicating
that the overall improvement in itching score after
follow-up 6 months was statistically not significant.
Table (6) illustrates that there was improvement
in the degree of pain after 2 weeks and 1 month
post-operative then deterioration of response at 6
months post-operative. p-value >0.05 indicating
that the overall improvement in pain score, after
follow-up 6 months, was statistically not significant.
Table (4): Comparison of surface appearance score followup
among study group.
Surface appearance
score
1: Similar to normal
2: Slight mismatch
3: Noticeably
rougher
4: Very rough
Before
No. (%)
0 (0%)
8 (40%)
8 (40%)
4 (20%)
After 2w
No. (%)
2 (10%)
6 (30%)
8 (40%)
4 (20%)
pvalue
0.6
After 1m
No. (%)
2 (10%)
6 (30%)
8 (40%)
4 (20%)
After 6m
No. (%)
2 (10%)
6 (30%)
8 (40%)
4 (20%)
Table (5): Comparison of itching score follow-up among study
group.
Itching score
0: No itching
1: Sometime itchy
2: Occasionally,
tolerable
Before
No. (%)
2 (10%)
15 (75%)
3 (15%)
After 2w
No. (%)
4 (20%)
14 (70%)
2 (10%)
pvalue
0.2
After 1m
No. (%)
12 (60%)
6 (30%)
2 (10%)
After 6m
No. (%)
8 (40%)
9 (45%)
3 (15%)
Table (1): Comparison of vascularity score follow-up among
study group.
Vascularity score
0: Normal color
1: Pink
2: Red
Before
No. (%)
10 (50%)
8 (40%)
2 (10%)
After 2w
No. (%)
10 (50%)
8 (40%)
2 (10%)
After 1m
No. (%)
10 (50%)
8 (40%)
2 (10%)
After 6m
No. (%)
10 (50%)
8 (40%)
2 (10%)
pvalue
0.1
Table (2): Comparison of pigmentation score follow-up among
study group.
After 6m
No. (%)
0 (0.0%)
5 (25%)
9 (45%)
6 (30%)
pvalue
0.1
After 1m
No. (%)
0 (0.0%)
5 (25%)
9 (45%)
6 (30%)
After 2w
No. (%)
0 (0.0%)
5 (25%)
9 (45%)
6 (30%)
Pigmentation score
0: Normal color
1: Hypopigmentation
2: Mixed pigmentation
3: Hyperpigmentation
Before
No. (%)
0 (0.0%)
5 (25%)
9 (45%)
6 (30%)
Pliability score
0: Normal
1: Supple(flexible with minimal resistance)
2: Yielding (moderate resistance)
3: Firm (inflexible, resistant to manual pressure)
4: Banding (rope-like tissue that blanches with extension of the scar)
After 6m
No. (%)
2 (10%)
6 (30%)
8 (40%)
4 (20%)
–
Table (3): Comparison of pliability score follow-up among study group.
pvalue
0.003*
After 1m
No. (%)
2 (10%)
6 (30%)
8 (40%)
4 (20%)
–
After 2w
No. (%)
2 (10%)
6 (20%)
10 (50%)
4 (20%)
–
Before
No. (%)
–
2 (10%)
6 (30%)
8 (40%)
4 (20%)
Table (6): Comparison of pain score follow-up among study group.
Pain score
0: No pain
1: Sometimes painful
2: Moderately irritable pain
Before
No. (%)
8 (40%)
10 (50%)
2 (10%)
After 2w
No. (%)
12 (60%)
8 (40%)
0 (0%)
pvalue
0.08
After 1m
No. (%)
16 (80%)
4 (2%)
0 (0%)
After 6m
No. (%)
12 (60%)
8 (40%)
0 (0%)
148 Vol. 44, No. 1 / Evaluation of Treatment of Post Burn Atrophic Scars
Fig. (1): (A,B): Pre-operative views of post-burn atrophic scar over the right cheek
(A: Right lateral view & B: Right oblique).
Fig. (1): (C,D): Outcome 6 months post-operatively (C: Right lateral view & D: Right
oblique view).
Fig. (2): (A,B): Pre-operative views of post-burn atrophic depressed scar over the posterior
surface of upper part of left thigh (A: Posterior view with pre-operative marking
& B: Left lateral view).
(A) (B)
(C) (D)
(A) (B)
Egypt, J. Plast. Reconstr. Surg., January 2020 149
Fig. (2): (C,D): Outcome 6 months post-operatively (C: Posterior view & D: Left lateral view).
Fig. (3): (A,B,C): Pre-operative views of two post-burn atrophic depressed scars over the forehead
(A: Frontal view & B: Right oblique view & C: Left oblique view).
Fig. (3): (D,E,F): Outcome 6 months post-operatively (D: Frontal view, E: Right oblique view &
F: Left oblique view).
(C) (D)
(A) (B) (C)
(D) (E) (F)
DISCUSSION
For post burn scar treatment autologous fat
graft and its regenerative properties has proved to
be a new possible chance for scar treatment [10].
The major advantages of autologous fat grafting
are as follows: Minimally invasive operation, short
hospital stay, ease of harvest and implantation, low
donor site morbidity, availability of fat and autologous
nature, easy to learn and practice, and minimal
complications in competent hands [11].
The major obstacle is an unpredictable and
often low graft survival, with resorption rates
ranging from 25% to 70%, which may be partly
related to insufficient vascularity of the transplant
[12].
In the current study, the centrifugation method
was used for processing of the harvested micro
fat. No decantation of the harvested fat was performed
in our study.
In agreement with that, Conde-Green et al.,
compared the content of adipocytes and mesenchymal
stem cells of fat grafts processed by decantation
or centrifugation. Although there are significantly
more viable adipocytes in the decanted group, the
fat grafts processed with decantation still contain
a great quantity of contaminating blood cells and
fewer stem cells [13].
In this study we evaluated the effect of micro
fat grafting on improving the quality and cosmetic
appearance of post-burn atrophic scars assessing
4 parameters of scar quality (vascularity, pigmentation,
pliability and surface appearance) via a
subjective aesthetic scar evaluation scale and we
also evaluated its effect on improving scar-related
symptoms (pain and itching) with post-operative
follow-up periods as follows: At 2 weeks, 1 month
and 6 months.
Regarding vascularity and pigmentation, there
were no statistical significance difference at postoperative
follow-up periods with p-value=1.000
(NS) indicating that is no effect of micro fat grafting
on improving the vascularity and pigmentation
scores.
The main improvement was noticed in the pliability
score which was statistically significant
after 2 weeks post-operative with p-value=0.001
(S). Further improvement was noticed after 1 month
post-operative which was statistically not significant,
p-value=0.3 (NS). There was no significant
changes after 6 months post-operative with p-value
=1.000 (NS).
150 Vol. 44, No. 1 / Evaluation of Treatment of Post Burn Atrophic Scars
Regarding surface appearance, there was minimal
improvement after 2 weeks post-operative
which was statistically not significant, p-value=
0.3 (NS). There was no significant changes after
1 month and after 6 months post-operative with pvalue=
1.000 (NS).
From the above results regarding the 4 parameters
of scar quality, we can notice that micro fat
has improved only the pliability of scars with no
improvement noticed in other parameters (vascularity,
pigmentation and surface appearance).
In agreement with these results, Sardesai and
Moore performed a study on fourteen patients with
various scar types treated with subdermal micro
fat grafting over 30 months. Dermal elasticity,
vascularity, pigmentation, pliability, patient perception
and satisfaction and observer assessment
of scar characteristics were evaluated preoperatively
and 1 year after treatment with validated
objective and subjective measures.
Sardesai and Moore concluded that microfat
grafting improved certain dermal characteristics
including elasticity, skin thickness, stiffness, and
pliability as evaluated by quantitative and validated
qualitative measures. Microfat grafting of cutaneous
scars did not appear to affect skin color (vascularity
& pigmentation) [14].
On the contrary, Brongo et al., performed fat
grafting on 18 patients with post-burn hypertrophic
scars and keloids, three times at 3-month interval,
noting better color, texture, thickness, elasticity
and a reduction of scar retraction at 1 year after
treatment [15].
Also, Klinger et al., concluded that injection
of processed autologous fat seems to be a promising
and effective therapeutic approach to scars of
different origin, and they confirmed that the treated
areas regain characteristics similar to normal skin,
with not only aesthetic but also functional results.
The treated skin becomes more elastic and softer
with significant improvement of color, shape,
thickness and movement was seen as early as 3
months post-operatively. Durometer evaluation
data showed a significant reduction in skin hardness
after autologous fat grafting, which demonstrates
efficacy in scar treatment [16].
Regarding itching, there was improvement after
2 weeks post-operative which was statistically not
significant, p-value=0.2 (NS). Further improvement
(accumulative effect) was noticed after 1 month
post-operative which was statistically significant,
Egypt, J. Plast. Reconstr. Surg., January 2020 151
p-value=0.03 (S). Recurrence of itching was noticed
after 6 months post-operative in 37.5% of cases
with p-value=0.09 (NS).
Regarding pain, there was improvement after
2 weeks post-operative which was statistically not
significant, p-value=0.08 (NS). Further improvement
was noticed after 1 month post-operative
which was statistically not significant too, p-value
=0.3 (NS). Recurrence of pain was noticed after 6
months post-operative in 50% of cases with pvalue=
0.2 (NS).
From the above results regarding scar-related
symptoms (pain and itching), we can notice that
micro fat has some degree of improvement on pain
& itching.
In agreement with these results, Fredman et al.,
focused on the improvement of neuropathic pain
on 7 patients with chronic, refractory neuropathic
pain, who underwent fat grafting to burn scars and
also reported improvement of color, texture, contour,
pliability and itching. Six of seven patients
had improvement in neuropathic pain after fat
grafting [17].
Also, Klinger et al., reported reduction in the
degree of pain in 376 patients with retractile and
painful scars of different origin treated with lipofilling
but there was no reduction in the degree of
itching after 12 months [16].
From all of the above results in the current
study, we can notice that the improvement in the
total score of aesthetic outcomes after 6 months
follow-up in comparison with the pre-operative
state with was mainly due to the improvement
noticed in the pliability of scar plus improvements
noticed in pain and itching.
In the current study, we can notice that microfat
grafting was superior in post-burn atrophic scars
as a good volume filler because of its filling character
rather than its minimal effect on improving
the quality of scars through improvement in the
pliability score only plus some improvement in
pain and itching.
Conclusion:
Micro fat has shown a significant improvement
in the pliability of scars, with maximum improvement
was after 2 weeks post-operative.
Also, some insignificant improvement was
noticed in pain and as regarding itching, there was
insignificant improvement after 2 weeks postoperative
and became significant after 1 month
post-operative.
On the other hand, there was no improvement
noticed in other parameters of scar quality (vascularity,
pigmentation and surface appearance).
Therefore, our clinical study concluded that
autologous micro fat grafting has a minimal effect
on improving the aesthetic outcomes of post-burn
atrophic scars and scar-related symptoms (pain &
itching) and much more great effect on restoring
volume contour and filling areas of volume deficits
of theses scars especially the depressed ones.
