Does Secondary Mechanical Manipulation of Lipoaspirate Enhance the Vasculogenic Potential of Fat Grafts? A Systematic Review.

BACKGROUND: Fat grafting is a highly versatile option in the reconstructive armamentarium but with unpredictable retention rates and outcomes. The primary outcome of this systematic review was to assess whether secondary mechanically processed lipoaspirate favorably enhances the vasculogenic potential of fat grafts when compared to unprocessed lipoaspirate or fat grafts prepared using centrifugation alone. The secondary outcome was to assess the evidence around graft retention and improved outcomes when comparing the aforementioned groups. METHODS: A search on MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials was conducted up to February 2022. All human and animal research, which provided a cross-comparison between unprocessed, centrifuged, secondary mechanically fragmented (SMF) or secondary mechanically disrupted (SMD) fat grafts, was included. RESULTS: Thirty-one full texts were included. Vasculogenic potential was assessed by quantification of angiogenic growth factors and cellular composition. Cellular composition of mesenchymal stem cells, perivascular stem cells, and endothelial progenitor cells was quantified by fluorescence activated cell sorting (FACS) analysis. Fat graft volume retention rates and fat grafting to aid wound healing were assessed. Although the presence of industry-funded studies and inadequate reporting of methodological data in some studies were sources of bias, data showed SMF grafts contain an enriched pericyte population with increased vascular endothelial growth factor (VEGF) secretion. Animal studies indicate that SMD grafts may increase rates of fat graft retention and wound closure compared to centrifuged grafts; however, clinical studies are yet to show similar results. CONCLUSIONS: In this systematic review, we were able to conclude that the existing literature suggests mechanically processing fat, whether it be through fragmentation or disruption, improves vasculogenic potential by enhancing angiogenic growth factor and relevant vascular progenitor cell levels. Whilst in vivo animal studies are scarce, the review findings suggest that secondary mechanically processed fat enhances fat graft retention and can aid with wound healing. Further clinical studies are required to assess potential differences in human studies.

Wide-Awake Hand Trauma Surgery: Designing Strategies to Optimise Patient Experience.

INTRODUCTION: The regional hand trauma service in Greater Manchester, United Kingdom, underwent significant reorganisation early in the COVID-19 pandemic, with a shift from predominantly general anaesthesia (GA) procedures to the adoption of a Wide-Awake Local Anaesthetic No Tourniquet (WALANT) technique. We implemented strategies targeted towards optimising patient experience, largely applicable to most healthcare settings. METHODS: Four domains were explored: (i) compliance in timing to nationally agreed treatment guidelines, (ii) the role of patient information leaflets, (iii) the introduction of a post-operative analgesia protocol, and (iv) broadly evaluating the environmental impact following the implementation of a same-day 'see and treat' service. RESULTS: Following reorganisation to a predominantly WALANT service, we observed an increase in compliance with nationally agreed standards for the treatment of common hand injuries. Patient education and peri-operative counselling reduced anxiety, whereas post-operative pain was better managed with the introduction of an analgesic protocol. Using a travel carbon calculator, it can be inferred that there are significant reductions in carbon emissions generated when patients are evaluated and treated on the same day as their clinical presentation. CONCLUSIONS: It is widely acknowledged that WALANT benefits patients and the healthcare system. We contemplated whether further incremental changes in clinical practice could further improve patient experience. Given our findings, we advocate a multi-modal approach with a greater focus on patient outcomes (trials are currently underway, e.g., WAFER) supplemented by universally accepted validated patient-reported outcome measures (PROMs).