1.Fat Transfer to the Upper and Lower Extremities in Patients With Raynauds Phenomenon A Novel Therapeutic Modality Jonathan Bank, MD, Sam A. Fuller, MD Ginard I. Henry, MD, Lawrence S. Zachary, MD Section of Plastic and Reconstructive Surgery Department of SurgeryNo disclosures

2. Fat Transfer to the Upper and Lower Extremities in Patients With Raynauds Phenomenon A Novel Therapeutic Modality Jonathan Bank, MD, Sam A. Fuller, MD Ginard I. Henry, MD, Lawrence S. Zachary, MD Section of Plastic and Reconstructive Surgery Department of Surgery 3. 3 Raynauds Phenomenon Vasodilation Vasoconstriction Fat Transfer in Raynauds 4. 4 Raynauds Phenomenon PrimaryVasoconstriction Cold attacks Pain Secondary Fibrosis Scarring Contracture Ulceration Autoamputation Fat Transfer in Raynauds 5. 5Fat Transfer in Raynauds Treatment Ca Channel Blockers ARB Protective Measures PDE-I Clopidogrel Endothelin Receptor Blockers Alpha Blockers Topical Nitrates ACE-I ASA Prostanoids 6. 6Fat Transfer in Raynauds Treatment Ca Channel Blockers ARB Protective Measures PDE-I Clopidogrel Endothelin Receptor Blockers Alpha Blockers Topical Nitrates ACE-I ASA Prostanoids Invasive Modalities Surgical Sympathectomy Neuro- modulators Fat Transfer 7. Clinical improvement radiation dermatitis, burns Histological evidence Sultan, PRS 2011 Radiation dermatitis murine model fat injection Regression of hyperpigmentation, ulcers and fibrosis Improvements in the inflammatory, microvascular, and fibrotic characteristics Mechanism unclear Restoration of depleted adipose-derived stem cells? 7Fat Transfer in Raynauds Fat Transfer Rationale Raynauds - different pathogenesis similar end effect 8. 8Fat Transfer in Raynauds Goal as a means to delay progression of Raynauds Phenomenon after failure of medical management Utilize fat grafting 9. Adaptation of rejuvenation of the hand by fat grafting Approximately 30 ml of decanted fat Abdominal depots Injected via blunt cannulae into the affected extremity 9Fat Transfer in Raynauds Technique 10. 10Fat Transfer in Raynauds Technique 10 ml - dorsum of hand 3 ml - snuff-box 2-3 ml - each dorsal webspace 6 ml - along palmar arch 1 ml - palmar webspaces 2-4 2 ml - first webspace 2 ml - ulnar border of small finger 11. 11Fat Transfer in Raynauds Technique 12. 12 Results Fat Transfer in Raynauds Total patients 14 Total extremities 25 Hand 20 Feet 5 Mean follow up 12 months (4-17) Female: Male 13:1 Primary: Secondary 8:6 Average fat injected 23.29 ml (10-30) Concomitant digital sympathectomy 4 13. 13 Results Overall improvement 92.5% of patients Pain reduction 85.7% (7 2.6) 1 patient no change 1 patient increased pain Cold attacks 78.5% decreased frequency and severity Ulcerations 66% improvement Major complications 0 Minor complications 2 Subsequent neuromodulator 1 Subsequent sympathectomy 1 Fat Transfer in Raynauds 14. 14Fat Transfer in Raynauds 15. 15Fat Transfer in Raynauds 16. 16Fat Transfer in Raynauds 17. 17Fat Transfer in Raynauds 18. 18Fat Transfer in Raynauds 19. 19Fat Transfer in Raynauds Hand Vascular Perfusion by Laser Doppler Normal Moderate Severe 20. 20Fat Transfer in Raynauds Hand Vascular Perfusion by Laser Doppler 21. 21Fat Transfer in Raynauds Hand Vascular Perfusion by Laser Doppler 22. 22Fat Transfer in Raynauds Preop Postop 200 150 100 50 Perfusionunits Hand Vascular Perfusion by Laser Doppler QMRADASH 23. Durable clinical improvement in the majority of treated patients Safe, relatively straightforward Mechanism to be elucidated (stem cell angiogenesis? padding?) Role in treatment of advanced, refractory Raynauds Phenomenon 23 Conclusions Fat Transfer in Raynauds