Progress in plastic surgery is not always a brilliant suc-
cess. There are also hard cornerstones – what not to do.
The authors made a significant contribution by providing
us with a negative result. The problem is common and
significant, and on initial examination seems simple.
The results of 77 operated wrists with recalcitrant car-
pal tunnel syndrome are presented. The crucial point is
the gliding of the median nerve (11–17 mm) within the
carpal tunnel during flexion-extension. Fibrous prolifera-
tions, longitudinal, not constricting traction forces, lead
to what disturbs the patient and what we call “recur-
rence”. Whatever reduces or prevents this gliding of the
median nerve at the wrist, e.g., pressure from the trans-
verse carpal ligament, causes the patient's symptoms and
leads him to see his physician. “To restore the movement
of the median nerve” (after complete sectioning of the
transverse carpal ligament) is the author's goal of therapy
– we agree with this.
Gliding of the median nerve, in this report, might be-
come possible by the addition of a 1 cm thick, 5 cm long
free fat graft to the routine decompression operation. No
difference in results was found whether a fat graft was
used or not, and we again agree: no additional free fat
graft in these cases.
Fat cells are round, movable against each other, and
may be compared to the elements of roller bearings. This
may explain the movement, e.g., of the skin against our
shin bone. The authors checked on free subcutaneous fat
grafts used in other situations. Why did these living fat
grafts not work?
The decisive question, as for every tissue transfer:
How does the free graft survive; how exactly is it vascu-
larized? A vascular pedicle (replanted arms do not suffer
from carpal tunnel syndrome), is not present here, or
vascular anastomoses between graft and graft bed. The
1. A well vascularized graft bed . There might be
some avascular scarring due to the first intervention.
A free skin graft, for example, does not take well over
abdominal fat .
2. Immobilization making vascular anastomoses be-
tween the free fat graft and its graft bed possible. In
the present series of patients, immobilization was for
10 days. This is sufficient for a free skin graft, as we
3. A well vascularized graft “ready” for vascular anasto-
moses. Traumatization of the graft reduces the deli-
cate vascularization parameters, and such traumatized
grafts are largely replaced by connective tissue .
The findings of Peer  reveal that about half of the fat
cells survive, depending on the amount of blood vessel
anastomoses between graft and graft bed.
In this paper, the task of the free fat graft is not only
its total or partial survival, it must also “restore the
movement of the median nerve”.
1. Clodius L, Smahel J (1972) Thin and thick pedicle flap. Acta
Chir Plast 14:30
2. Peer LA (1959) Transplantation of tissues. Vol. II. William &
3. Peer LA (1950) Loss in weight and volume of human fat. Plast
Reconstr Surg 5:217
This commentary refers to the article: http://dx.doi.org/10.1007/
L. Clodius (
) · I. Niechajev
Seefeldstrasse 4, 8008 Zurich, Switzerland
Eur J Plast Surg (2001) 24:18
L. Clodius · I. Niechajev
Comment on: The use of free fat grafts in recalcitrant carpal tunnel:
a retrospective study by B.E. Impelmans et al.
Published online: 2 February 2001
© Springer-Verlag 2001