Can Fat Pad Restoration Play More Of A Role In Preventing Ulcer Recurrence?

This blog piggybacks on a recent blog “Educating Patients On Mobility Improvement After A Healed Ulceration,” written by David G. Armstrong, DPM, MD, PhD.”¹ 

Dr. Armstrong’s blog discusses a publication highlighting the five most important factors for a patient who has a healed ulceration.² These points are valid and make complete sense. These concepts should be at the forefront of discussions with your patients as steps to employ in the home. 

As I read the blog, I was hoping to see one more key component that should become a standard of care over the next decade: fat pad restoration.

Fat pad restoration is geared toward restoring the natural padding to the subcutaneous layer of the patient’s foot. The purpose in performing this procedure is to decrease peak pressure forces associated with weightbearing and provide an internal pad the patient can use as a shock absorption mechanism. By decreasing the pressure and load placed on the dermal tissues, one can decrease the breakdown of the skin. 

When a patient heals from an ulceration, he or she is often left with loss of tissue in the subcutaneous region due to an increase in scarring and poorly organized collagen orientation of the skin. Fat pad restoration techniques provide an internal pad that helps restore collagen and tissue layers in a more normalized fashion.³ 

Another benefit of fat pad restoration is for the neuropathic patient who may not be as adherent to advice. In my experience, adherence with the use of orthotics and custom shoes is diminished when a patient suffers from neuropathy. Even with appropriate patient education, most people with neuropathy tend to walk barefoot in the home.⁴ 

Walking barefoot can also lead to wound recurrence. In my experience, we should consider fat pad restoration for ulceration prevention and to reduce the incidence of ulcer recurrence. 

The use of dermal fillers, allograft adipose matrix and autologous fat transfer are all good methods for fat pad restoration. One performs this in an office or outpatient facility such as a hospital ambulatory surgery center or wound care center, placing the substance into the subcutaneous tissue layer. The patient continues to offload for two to four weeks with padding, CAM boot or contact casting. The length of time the substance lasts is not yet clear and experience shows that this varies with factors including comorbidities, smoking, severity of fat atrophy and foot type.

Dr. Schoenhaus is a Diplomate of the American Board of Foot and Ankle Surgery. She is in private practice in Boca Raton and Boynton Beach, Fla. One can follow Dr. Schoenhaus online at @bocafootandveindoc and www.bocaratonfootcare.com.

References

1. Armstrong DG. Educating patients on mobility improvement after a healed ulceration. Podiatry Today. Available at: https://www.podiatrytoday.com/blogged/educating-patients-mobility-improvement-after-healed-ulceration . Published March 5, 2020. Accessed March 13, 2020.
2. Mueller MJ. Mobility advice to help prevent re-ulceration. Diab Metab Res Rev. 2019;36 Suppl 1:e3259. doi: 10.1022/dmrr.3259. 
3. Farber SE, Minteer D, Gusenoff BR, Gusenoff JA. The influence of fat grafting on skin quality in cosmetic foot grafting: a randomized, cross-over clinical trial. Aesthet Surg J. 2019;39(4):405-412.
4. Barwick AL, van Netten JJ, Hurn SE, Reed LF, Lazzarini PA. Factors associated with type of footwear worn inside the house: a cross-sectional study. J Foot Ankle Res. 2019;12:45.