Fat Grafting to the Hand in Patients with Raynaud Phenomenon

Sir: We read with great interest the article by Bank et al.1 published recently on fat injection in hands of patients with Raynaud phenomenon aiming to delay the progression of the disease. Their results appear very interesting considering the fact that important improvement was achieved and no major complications were observed. The use of fat injections in hand therapy or cosmetics is not new.2–4 However, there has been a recent increase of fat injection use for different indications.5 An 84-year-old female patient presented to our service with bilateral, 10-digit ischemia, with no ulceration. The patient gave no previous history of diabetes mellitus or medication that could be associated with Raynaud syndrome. However, the patient’s history reveals alcoholism in the past two decades. She had a history of scleroderma and was on endothelin-1 receptor antagonists and two injection sessions of neuromodulators (botulinum toxin) 6 months before our first consultation. She was scheduled for fat injection 3 days after admission. The patient was injected with 28 ml of decanted fat in the left hand and 27 ml in the right. She presented 10-digit ischemia 36 hours postoperatively that did not respond to neuromodulators or intravenous prostanoids. Eventually, she developed 10-digit necrosis that was treated surgically (Figs. 1 and 2). Interestingly, the patient also developed nose tip necrosis simultaneously, which was also treated surgically.Fig. 1: Five-digit necrosis of the right hand.Fig. 2: Five-digit necrosis of the left hand.Although many of the present data described are valuable and interesting, we believe that certain factors need further investigation and clarification. It seems that the patient’s age might play a role in the reversibility of digital ischemia, possibly affecting the balance between vasoconstriction and vasodilatation. In our case, fat injection did not help compromised digital perfusion, and it appeared as if it triggered a reaction possibly related to the fat injection. This conclusion could be based on the observation of simultaneous nasal tip ischemia. Another factor that could possibly play a role is chronic use of alcohol and its possible destabilizing influence on digital vasoconstriction/vasodilatation. In conclusion, although Bank et al. presented important issues in their serious study, there are limitations concerning the article’s sample size. Further investigation needs to be performed to determine the nature of Raynaud phenomenon and how it interacts in different circumstances with fat injection technique. In our hands, use of this technique did not prove safe and reliable. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Leonidas Pavlidis, M.D., Ph.D. Stamatis Sapountzis, M.D., Ph.D. Georgia Alexandra Spyropoulou, M.D., Ph.D. Efterpi Demiri, M.D., Ph.D. Aristotle University of Thessaloniki Thessaloniki, Greece