Comment on: The use of free fat grafts in recalcitrant carpal tunnel: a retrospective study by B.E. Impelmans et al.

Comment on: The use of free fat grafts in recalcitrant carpal tunnel: a retrospective study by... Eur J Plast Surg (2001) 24:18 DOI 10.1007/s002380000220 INVITED COMMENTAR Y 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 Progress in plastic surgery is not always a brilliant suc- The decisive question, as for every tissue transfer: cess. There are also hard cornerstones – what not to do. How does the free graft survive; how exactly is it vascu- The authors made a significant contribution by providing larized? A vascular pedicle (replanted arms do not suffer us with a negative result. The problem is common and from carpal tunnel syndrome), is not present here, or significant, and on initial examination seems simple. vascular anastomoses between graft and graft bed. The The results of 77 operated wrists with recalcitrant car- prerequisites are: pal tunnel syndrome are presented. The crucial point is the gliding of the median nerve (11–17 mm) within the 1. A well vascularized graft bed [1]. There might be carpal tunnel during flexion-extension. Fibrous prolifera- some avascular scarring due to the first intervention. tions, longitudinal, not constricting traction forces, lead A free skin graft, for example, does not take well over to what disturbs the patient and what we call “recur- abdominal fat [2]. rence”. Whatever reduces or prevents this gliding of the 2. Immobilization making vascular anastomoses be- median nerve at the wrist, e.g., pressure from the trans- tween the free fat graft and its graft bed possible. In verse carpal ligament, causes the patient's symptoms and the present series of patients, immobilization was for leads him to see his physician. “To restore the movement 10 days. This is sufficient for a free skin graft, as we of the median nerve” (after complete sectioning of the all know. transverse carpal ligament) is the author's goal of therapy 3. A well vascularized graft “ready” for vascular anasto- – we agree with this. moses. Traumatization of the graft reduces the deli- Gliding of the median nerve, in this report, might be- cate vascularization parameters, and such traumatized come possible by the addition of a 1 cm thick, 5 cm long grafts are largely replaced by connective tissue [2]. free fat graft to the routine decompression operation. No difference in results was found whether a fat graft was The findings of Peer [3] reveal that about half of the fat used or not, and we again agree: no additional free fat cells survive, depending on the amount of blood vessel graft in these cases. anastomoses between graft and graft bed. Fat cells are round, movable against each other, and In this paper, the task of the free fat graft is not only may be compared to the elements of roller bearings. This its total or partial survival, it must also “restore the may explain the movement, e.g., of the skin against our movement of the median nerve”. shin bone. The authors checked on free subcutaneous fat grafts used in other situations. Why did these living fat grafts not work? References This commentary refers to the article: 1. Clodius L, Smahel J (1972) Thin and thick pedicle flap. Acta s002380000219 Chir Plast 14:30 2. Peer LA (1959) Transplantation of tissues. Vol. II. William & L. Clodius ( ) · I. Niechajev Wilkins, Baltimore. Seefeldstrasse 4, 8008 Zurich, Switzerland 3. Peer LA (1950) Loss in weight and volume of human fat. Plast Tel.: +41-1-2525522 Reconstr Surg 5:217 European Journal of Plastic Surgery Springer Journals

Comment on: The use of free fat grafts in recalcitrant carpal tunnel: a retrospective study by B.E. Impelmans et al.

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Copyright © 2000 by Springer-Verlag
Medicine & Public Health; Plastic Surgery
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