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Journal of Investigative Surgery
ISSN: (Print) (Online) Journal homepage: https://www.tandfonline.com/loi/iivs20
Possibility of Taking an Offensive Stance in
Extravasation Injury: Effects of Fat Injection in
Vesicant (Doxorubicin) Induced Skin Necrosis
Model in Rats
Ahmet Bicer, Burak Sercan Ercin, Tahir Gürler, Gürkan Yiğittürk, Yigit
Uyanikgil & Emel Oyku Cetin
To cite this article: Ahmet Bicer, Burak Sercan Ercin, Tahir Gürler, Gürkan Yiğittürk, Yigit Uyanikgil
& Emel Oyku Cetin (2021): Possibility of Taking an Offensive Stance in Extravasation Injury:
Effects of Fat Injection in Vesicant (Doxorubicin) Induced Skin Necrosis Model in Rats, Journal of
Investigative Surgery, DOI: 10.1080/08941939.2021.1966142
To link to this article: https://doi.org/10.1080/08941939.2021.1966142
Published online: 17 Aug 2021.
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ORIGINAL RESEARCH
JOURNAL OF INVESTIGATIVE SURGERY
Possibility of Taking an Offensive Stance in Extravasation Injury: Effects of
Fat Injection in Vesicant (Doxorubicin) Induced Skin Necrosis Model in Rats
Ahmet Bicera, Burak Sercan Ercinb,c, Tahir Gürlera, Gürkan Yiğittürkd, Yigit Uyanikgile,f, g
and Emel Oyku Cetinh
aDepartment of Plastic Surgery, Faculty of Medicine, Ege University, Izmir, Turkey; bDepartment of Plastic, Reconstructive and Aesthetic
surgery, Bahcesehir University, Istanbul, Turkey; cDepartment of Plastic, Reconstructive and Aesthetic surgery, Medicalpark Pendik Hospital,
Istanbul, Turkey; dDepartment of Histology and Embryology, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey;
eDepartment of Histology and Embryology, Faculty of Medicine, Ege University, Izmir, Turkey; fDepartment of Stem Cell, Ege University,
Health Science Institue, Izmir, Turkey; gCord Blood, Cell and Tissue Research and Application Centre, Ege University, Izmir, Turkey;
hDepartment of Pharmaceutical Technology, Department of Biopharmaceutics and Pharmacokinetics, Faculty of Pharmacy, Ege University,
Izmir, Turkey
ABSTRACT
Introduction: Extravasation injuries are one of the most feared complications of intravenous drug
administration. The most common drugs associated with extravasation injury include chemotherapy
agents and contrast media. Natural course of vesicant extravasation is discomfort, pain, swelling,
inflammation, and ultimately skin ulceration. While diligence is the principle approach in prevention,
immediate bed-side measures are as important in controlling the extent of tissue damage. Various
options, either medical or interventional are next steps in treatment of the condition including
antidotes, volume dilution, flushing, suction, hyperbaric oxygen therapy, and surgery.
Materials and methods: 12 male Wistar albino rats were divided into two groups; one group
received fat injections following subdermal doxorubicin infiltration in their right thighs, while other
group received saline injection following subdermal doxorubicin infiltration in their right thighs
for dilution. Left thighs of both groups were left untreated following subdermal doxorubicin
infiltration. Total area of necrosis, as well as resultant epidermal thicknesses were assessed.
Histological analyses were conducted using modified Verhofstad scoring system for comparison.
Results:Mean necrotic area was significantly smaller in the fat injection group compared to other
groups. Median Verhofstad score was lesser in the fat injection group as well. Median epidermal
thickness, on the other hand, was greater in the fat injection group.
Conclusion:Injection of fat grafts following vesicant extravasation might be beneficial in preventing
the progression of tissue damage, if employed early.
Introduction
Unintentional leakage of substances to the interstitial space
which are otherwise meant for intravenous use, is a relatively
common phenomenon in clinical setting. If the leaked sub-
stance is a neutral or non-vesicant type, it can be defined
as a rather benign process called infiltration [1]. However,
extravasation injury is a step further and fortunately less
common. It dictates that the extravasated solution being
toxic to the native tissues (vesicant) when leaked to the
interstitial space [2]. In between lies the irritant drugs that
can cause pain along the administration route or extrava-
sation site with or without inflammation, however causing
ulceration only if in significant quantities [3,4]. Consequences
of drug infiltration or extravasation may be varied; from
minor discomfort, pain, and swelling to widespread inflam-
mation or stubborn ulceration [5].
Intravenous drugs were comprehensively classified with
respect to their potential to cause harm when leaked
extravascularly: (i) vesicants (e.g., actinomycin, doxorubicin,
mitomycin C, vincristine), (ii) exfoliants (lower vesicant
potential, often causing peeling off skin without tissue necro-
sis. e.g., cisplatin, paclitaxel), (iii) irritants (drugs that can
cause significant pain, irritation, and inflammation without
blister formation. e.g., topotecan, bleomycin), (iv) inflam-
mitants (drugs that cause mild inflammation, redness and
swelling without severe pain. e.g. methotrexate, 5-fluorouracil),
and (v) neutrals (drugs causing no signs of irritation or
inflammation such as monoclonal antibodies, bleomycin,
cyclophosphamide) in descending order of potential to cause
harm when leaked to extravascular spaces [6]. As given in
the examples of aforementioned classification, the most com-
mon drugs related to extravasation injuries are chemother-
apeutical agents that can be further divided into two main
categories as DNA binding and DNA non-binding [3].
As most of those drugs are a part of a regimen admin-
istered to patients with oncologic or rheumatologic disease,
© 2021 Taylor & Francis Group, LLC
CONTACT Emel Oyku Cetin emel.oyku.cetin@ege.edu.tr Department of Pharmaceutical Technology, Department of Biopharmaceutics and Pharmacokinetics,
Faculty of Pharmacy, Ege University, Bornova - Izmir, Turkey.
https://doi.org/10.1080/08941939.2021.1966142
ARTICLE HISTORY
Received 7 May 2021
Accepted 2 August 2021
KEYWORDS
Extravasation; fat injection;
regenerative medicine;
chemotherapeutics; iatrogenic
injury
2 A. BICER ET AL.
a higher overall complication rate should be expected. These
patients are not only prone to healing problems, but also
bear significant challenges in providing a venous access [7].
Treatment of extravasation after the fact is difficult, and
besides supportive bedside care recommended by many
authors, there are only a limited number of studies available
demonstrating the efficacy of several antidotes in the liter-
ature including dimethyl sulfoxide, hyaluronidase, heparin,
dexrazoxane, large volume saline, and steroids [8–12].
Depending on the severity of the local tissue damage and
response, surgical intervention may be considered.
Full-thickness skin slough and chronic ulceration warrant
for complete resection of the necrotic tissue, assessment of
the remainder tissue and decision to reconstruct immediately
or stage debridement in anticipation of further tissue loss
[8,13]. Fasciotomies may be needed in case of impending
compartment syndrome [14]. Hyperbaric oxygen therapy
may be useful in selected cases [14].
Regenerative medicine can be defined as a sum of strat-
egies to restore the integrity of lost tissue. Its characteristic
difference from tissue repair is regaining the lost tissue’s
main form and function, whereas for the former, repaired
tissue is destined with scar formation [15,16]. Rejuvenation,
regeneration, and replacement constitute to the three Rs of
modern view of regenerative medicine [17].
Current regenerative approaches utilized in clinical prac-
tice for wound management include autologous keratinocytes
for extensive burns, autologous adipose derived stem cells
for a multitude of conditions, dermal fibroblasts for epider-
molysis bullosa, allogenic placenta-derived cells and tissue
for chronic wound healing, and many others [18–20]. Early
level clinical trials address their potential benefit in array
of disorders such as Parkinson’s (embryonic dopamine neu-
rons) [21], spinal cord injury (repetitive stem cell injections)
[22], multiple sclerosis [23], macular degeneration [24],
post-ischemic and dilated cardiomyopathy [25], liver cirrho-
sis [26], endocrine disorders [27–29], transplant rejection/
tolerance [30], among many others.
Structural fat grafting has been used in plastic surgery
frequently since 1980s especially after popularization of
lipoaspiration procedures [31]. Significant regenerative
effects of grafted fat have been observed by various authors
coming from various backgrounds including cardiology, neu-
rology, orthopedic surgery, among others ever since [32,33].
Other than volume restoration, fat grafts have been success-
fully used as regenerative tools in plastic surgery practice
for radiation dermatitis, management of hypertrophic and
atrophic scars, lichen sclerosis, rhytids of aging face, and
various pigmentation problems [34–36].
Fat grafts obtained by lipoaspiration do not only include
mature adipocytes, but also significant amount of stromal
vascular fraction (SVF) and mesenchymal pluripotent stem
cells [37]. SVF is basically a collection of cells and growth
factors including lymphocytes, macrophages, stem cells, peri-
cytes, and preadipocytes; most of which is associated with
regeneration and/or maintenance of regenerative potential
of stem cells [38].
Lipoaspiration material obtained with standard 3 mm
cannula is called macrofat. It is still rich in mature adipo-
cytes and principally used in structural fat injections to
reconstruct soft tissue volume. Mechanically slicing or fil-
tering the same material through 1 mm sharp-edge fenes-
trated cannula is called microfat. This preparation contains
higher density of stem cells and SVF, while retaining some
of viable mature adipocytes. Unlike nanofat, which can be
obtained mechanically or enzymatically, comprising only of
stem cells and SVF, and no viable adipocytes [39].
In this study, effects of fat grafts in the treatment of
extravasation injury induced with one of the most prominent
vesicants in clinical use, doxorubicin have been investigated
in a rat model. The aim of this study was to evaluate the
effect of microfat injections in the treatment of extravasa-
tion injury.
Materials and Methods
Animal Model
İstanbul Demiroğlu Bilim University Animal Ethics
Committee has approved the study (Registration No.
06210519). The study included 12 male Wistar albino rats
with an average weight of 250–300 g. The rats were housed
in cages at a temperature of 20 °C–22 °C with a 12-h light
and dark cycle before the surgical intervention. Water and
nutrients were given ad libitum.
Induction of Extravasation Injury
Following intraperitoneal injection of 80 mg/kg ketamine
and 10 mg/kg xylazine and preparation of the dorsal thigh
regions, 1.0 mg/mL doxorubicin solutions were injected to
immediate subdermal plane of both upper dorsal thigh
regions to induce a standard extravasation injury as pro-
posed by Yilmaz et al [40].
Study Groups
The rats are randomly divided into treatment (a total of six
rats in the group; both thighs were infiltrated with doxo-
rubicin, left thighs -annotated as group 1- left untreated,
right thighs -annotated as group 2- were treated with fat
injection) and control (a total of six rats in the group; both
thighs were infiltrated with doxorubicin, left thighs -anno-
tated as group 3- left untreated, right thighs -annotated as
group 4- were treated with saline injection) groups (Figure
1). Fat grafts were obtained from bilateral inguinal fat pads
and they were minced after excision until they were con-
veniently able to pass through a 2 mm (12 G steel) transfu-
sion needle. Following bilateral subdermal infiltration with
doxorubicin, left thighs are left untreated to determine a
baseline for amount of tissue necrosis in all groups (groups
1 and 3). In the treatment group fat grafts were injected in
right thighs (group 2), while control group received equiv-
alent amount of saline infiltration to their right thighs
(group 4).
At 14th day following surgery, the rats were sacrificed
with lethal dose (triple anesthetic dose) anesthetic injection,
standard photographs of the necrotic areas were obtained.
Excisional biopsies of the inguinal integument were
collected.
JOURNAL OF INVESTIGATIVE SURGERY 3
Histological Analysis
After fixation of the skin biopsy samples with 10% buffered
formalin for 24 h, routine paraffin wax embedding proce-
dures were used, and the samples were solidified in blocks.
About 5 mm sections were cut using a Leica RM 2145™
microtome (Leica Biosystems GmbH, Wetzlar, Germany),
which were then stained with both Hematoxylin-Eosin and
Mallory Azan staining. Sections were evaluated at a mag-
nification of 40x, and epithelial thickness were examined.
After taking digital photos (Olympus BX51 Light Microscope,
Olympus C5050 Digital Camera, Olympus Corporation,
Shinjuku, Tokyo, Japan) at a magnification of 20x, necrotic
skin and total flap area border were determined with the
aid of a software program (Image-Pro Express Version
4.5.1.3., Media Cybernetics Inc., Rockville, Maryland, USA,
2002). A modified version of Verhofstad scoring system was
used to evaluate histological parameters [41,42]. Under light
microscope 40x magnification two random consecutive areas
were assessed for necrosis, edema, polymorph nuclear leu-
kocyte (PMNL) infiltration, collagen discoloration, neovas-
cularization, and follicular density in each region were
detected and recorded.
Immunohistochemical Analysis
To analyze the immunohistochemical expressions, antibodies
against inducible nitric oxide synthase (Anti-iNOS) and
vascular endothelial growth factor (Anti-VEGF) were used.
Paraffin sections were immersed in xylene overnight and
incubated in methanol containing 3% hydrogen peroxide to
reduce endogenous peroxidase activity. Sections were heated
in sodium citrate solution in a microwave oven at 90 W for
5 min and at 360 W for 15 min. Subsequently, sections were
incubated in primary antibodies (anti-VEGF; 1/100 and
anti-iNOS, Santa Cruz, Sc-651; 1/100) for 24 h at 4 °C.
Antibody detection was performed with the Histostain-Plus
Bulk kit (Bioss, Inc.) against rabbit IgG, and 3,
30-diaminobenzidine was used to visualize the final product.
Immunoreaction was assessed by light microscopy (Olympus
BX-51 light microscope, Olympus C-5050 digital camera)
at 40x magnification.
Statistical Analysis
Data analysis was performed with SPSS (IBM SPSS Statistics
for Mac, Version 21.0, IBM Corp., Armonk, NY, USA).
The distribution of variables and normality were investi-
gated using descriptive statistics, direct visualization of the
data histogram for kurtosis and skewness, detrended Q-Q
plot analyses, and a non-parametric normality test was
run (Shapiro-Wilk). Mean, standard deviation, median, and
interquartile range values were used for descriptive statis-
tics. As the measurements for total area of necrosis were
normally distributed and variances were homogenous, the
one-way ANOVA test was conducted to compare variances
of necrotic areas between groups. A Tukey post-hoc anal-
ysis was followed through with to explore the intergroup
differences. Measurements regarding the epidermal thick-
ness were not normally distributed so the Kruskal-Wallis
test was used to compare median epidermal thickness
between groups. Post-hoc analyses were run with the Mann
Whitney U test, as level of two-tailed significance was
rectified with Bonferroni corrections (p = 0.00833).
Histologic scores comprising the modified Verhofstad scale
were ordinal in quality, so the Kruskal-Wallis test was used
to compare median scores among groups. Post-hoc analyses
were run with the Mann Whitney U test, as level of
two-tailed significance was rectified with Bonferroni cor-
rections (p = 0.00833). The two-tailed significance level was
set as p = 0.05.
Results
Area of Necrosis
The mean area of necrosis in the left thighs of the treatment
group (group 1, doxorubicin only) was 7,99 (±2,09) cm2,
right thighs of the treatment group (group 2, doxorubicin
and fat injection) was 4,38 (±1,02) cm2, left thighs of the
control group (group 3, doxorubicin only) was 8,00 (±1,73)
cm2, and right thighs of the control group was 7,90 (±1,50)
cm2 (Figure 2). The area of necrosis in the fat injection
group was significantly smaller compared both to control
groups (p = 0,005), and saline injected thigh (p = 0,006)
(Figure 3).
Figure 1. Grouping of the animals’ thighs. Left thighs of both groups were left untreated following doxorubicin injection. Right thighs of the animals in the
study group received fat injections, while right thighs of the control group received saline injections.
4 A. BICER ET AL.
Figure 3. Dorsal view of the rat caudal portions fol owing injections and after onset of the necrosis. A-F: the animals whose right thighs received fat injections
(DR + fat injections) while left thighs left untreated (DR only) to take the natural course. G-L: the animals whose right thighs received saline injections (DR + saline
injections) while left thighs left untreated (DR only) to take the natural course.
Histological Analysis
Microscopic examination of the epidermis yielded intense
wound foci in the doxorubicin-only groups. Hair roots and
sebaceous glands were completely degenerated. There were
discoloration and deformation findings in collagen fibers in
the dermis. A decrease in connective tissue cells and fibers
has been detected. INOS and VEGF expression was not
detected. In the fat injection group, although there were
bleeding foci in the epidermis, it was observed that the
epidermis had normal histological structure. It was found
that collagen fibers with tight connective tissue properties
were preserved in the stratum reticularis layer. Compared
with the other two control groups, a highly preserved/
improved histopathological appearance was dominant. INOS
expression was locally present in the epidermis and deep
dermis cells while VEGF expression was present, albeit
scarce. As for the saline dilution group, there was a histo-
pathological distribution similar to the doxorubicin-only
group; INOS and VEGF expression was not detected.
Figure 2. Mean necrosis area is signicantly smaller in the fat injection group
compared to saline and no treatment controls. CI: condence interval, DR:
doxorubicin, DR + Fat: doxorubicin and fat injection, DR + Saline: doxorubicin
and saline injection groups.
JOURNAL OF INVESTIGATIVE SURGERY 5
However, there was expression in the muscle tissue in this
section (Figures 4 and 5).
The median Verhofstad score in group 1 was 16 (IQR,
15–17), in group 2 it was 12 (IQR, 11–13), in group 3 it
was 17 (IQR, 15–18), and in group 4 it was 17 (IQR, 16–17).
Total Verhofstad index was significantly lower in the fat
injection group compared to control groups, and saline
group (p = 0,004 each) (Figure 6). A detailed analysis of the
components of the Verhofstad scale revealed that for all
parameters except for neovascularization, there was a sig-
nificant difference between control groups, and fat injection
group (Figure 6).
The median epidermal thickness in group 1 was 14,90
(IQR, 14,67–16,79) μm, in group 2 it was 22,80 (IQR,
22,35–24,52) μm, in group 3 it was 15,39 (IQR, 14,23–16,73)
μm, in group 4 it was 16,30 (IQR, 14,90–16,97) μm (Figure
7). Epidermal layer of the fat injection group was signifi-
cantly thicker compared both to control groups (p = 0,004),
and saline injected thigh (p = 0,004). The results are sum-
marized in Table 1.
Discussion
The most important finding of this study was that microfat
injection found to be superior to both wait-and-see and
volume dilution methods in the treatment of extravasation
injury in rats caused by infiltration with a vesicant agent,
doxorubicin. These findings supported that fat injections
Figure 4. Microscopic view of the soft tissue envelope overlying the injury sites. G1A: sample from “doxorubicin only” group, HE staining, x20 magnication,
G1B: sample from “doxorubicin only” group, Mallory-Azan staining, x20 magnication, G2A: sample from “doxorubicin + fat injection” group, HE staining, x20
magnication, G2B: sample from “doxorubicin + fat injection” group, Mallory-Azan staining, x20 magnication, G3A: sample from “doxorubicin only” group, HE
staining, x20 magnication, G3B: sample from “doxorubicin only” group, Mallory-Azan staining, x20 magnication, G4A: sample from “doxorubicin + saline dilution”
group, HE staining, x20 magnication, G4B: sample from “doxorubicin + saline dilution” group, Mallory-Azan staining, x20 magnication. Blue arrows: necrotic
area.
Figure 5. Microscopic ndings continued. G1C: sample from “doxorubicin only” group, Anti-iNOS staining, x20 magnication, G1D: sample from “doxorubicin
only” group, Anti-VEGF staining, x40 magnication, G2C: sample from “doxorubicin + fat injection” group, Anti-iNOS staining, x20 magnication, G2D: sample
from “doxorubicin + fat injection” group, Anti-VEGF staining, Blue arrow: immunopositive vessel. x40 magnication, G3C: sample from “doxorubicin only” group,
Anti-iNOS staining, x20 magnication, G3D: sample from “doxorubicin only” group, Anti-VEGF staining, x40 magnication, G4C: sample from “doxorubicin + saline
dilution” group, Anti-iNOS staining, x20 magnication, Yellow arrow: immunopositive muscle tissues. G4D: sample from “doxorubicin + saline dilution” group,
Anti-VEGF staining, x40 magnication.
6 A. BICER ET AL.
Figure 6. Median Verhofstad score is signicantly smaller in the fat injection
group compared to saline and no treatment controls. DR: doxorubicin, DR + Fat:
doxorubicin and fat injection, DR + Saline: doxorubicin and saline injection
groups.
Figure 7. Median epidermal thickness is signicantly greater in the fat injection
group compared to saline and no treatment controls. DR: doxorubicin, DR + Fat:
doxorubicin and fat injection, DR + Saline: doxorubicin and saline injection
groups.
Table 1. Summary of the statistical analyses outlining the signicant dierences between fat transfer and control groups.
Group 1 (DR only)
Group 2 (DR + Fat
Injection) Group 3 (DR Only) Group 4 (DR + Saline) Pa
Necrotic Areab7,99 (+/−2,09) 4,38 (+/−1,02) 8,00 (+/−1,73) 7,90 (+/−1,50) <0.05
Verhofstad
Scorec
Necrosis 4 (3–4) 2 (2–2) 4 (4–5) 4 (3–4) <0.05
Edema 3 (3–3) 2 (1–2) 3 (3–3) 3 (3–3) <0.05
PMNL inltration 3 (3–4) 2 (1–2) 4 (3–4) 4 (3–4) <0.05
Collagen Discoloration 3 (3–4) 2 (1–2) 4 (3–4) 4 (3–4) <0.05
Follicular Density 1 (1–1) 2 (2–2) 1 (1–1) 1 (1–2) <0.05
Neovascularization 1 (0–2) 3 (2–3) 1 (0–2) 1 (1–2) >0.05
Total 16 (15–17) 12 (11–13) 17 (15–18) 17 (16–17) <0.05
Epidermal
Thicknessd
14,90 (14,67–16,79) 22,80 (22,35–24,52) 15,39 (14,23–16,73) 16,30 (14,90–16,97) <0.05
aGroup comparisons were made with the ANOVA test to compare means of the necrotic area; a Tukey post-hoc test was conducted next. The median values
of the Verhofstad scale and epidermal thickness were compared with the Kruskal-Wallis test; intergroup comparisons were made with the Mann-Whitney U
test as post-hoc analyses while p values were corrected with Bonferroni technique.
bNecrotic area in cm2. Mean and standard deviation.
cTotal and components of the Verhofstad scale scores in integers. Median and interquartile range.
dEpidermal thickness in m. Median and interquartile range.
decreased total necrosis area and increased epidermal
thickness.
Extravasation injuries present as severe pain and swelling,
followed by inflammation, and tissue necrosis. As far as
extravasation injury is concerned, vigilance is the principal
merit in prevention or limitation of damages. However, once
occurred there are consequences causing long term mor-
bidities. Discontinuation of the drug, supportive patient care
including elevation of the affected extremity, cold or hot
compresses depending on the desired effect, analgesic ther-
apy, and administration of antidotes (if any known) have
constituted the crucial steps in the treatment algorithm
[3,43]. Next step includes invasive procedures.
Fenestration of the affected skin and extraction of the
extravasated intravenous contrast solution is reported by
Tsai et al. to be successful in a single case series of eight
consecutive patients [44]. However, this technique somewhat
lacks repeatability and requires substantial diligence, and
maybe better suited for less harmful agents such as con-
trast media.
Diluting the concentrations of the extravasated drug by
flushing the extravasation space by saline [45], and even
further, suctioning the volume with liposuction cannula
[46–48] are shown to be effective methods, especially if
employed early.
When conservative options fail to prevent tissue necrosis
or the critical time before irreversible damage is missed,
surgical options including debridement and immediate or
delayed reconstruction with skin grafts or soft tissue flaps
should be considered [49]. Non-adhesive or occlusive dress-
ings are useful if there is question about tissue vitality or
in the course of patients’ preparation to surgery [50].
Despite being a widespread and dreadful iatrogenic injury,
experimental studies comparing different treatment options
are scarce. Chacon mentioned their rat model of extrava-
sation injury with doxorubicin infiltration, and subsequent
treatment with stab incisions and saline flushing [51]. With
vigorous flushing, they observed later onset of ulcer, earlier
healing, and smaller ulcer area.
A standardized method of induction of a rat extravasation
injury model with doxorubicin was developed by Yilmaz
JOURNAL OF INVESTIGATIVE SURGERY 7
et al [40]. In their excellent work with 99 rats, not only
they found out the minimum dose of doxorubicin to induce
a measurable amount of tissue damage, but they also com-
pared effectiveness of several methods in limiting the size
of necrosis [40].
Limitations of this study include rather small number
of animals included in the groups. Furthermore, contralat-
eral thighs were used as control to fat and saline injection
sides. This design was intentionally chosen for it to be
compatible with three Rs principle (replace, reduce, and
refinement) of animal experiments. Another limitation of
this study is what shown here was merely an experimental
study with level V evidence. Beneficial effects of different
types of fat grafts, such as microfat, macrofat, and nanofat
should be investigated clinically and experimentally. Microfat
grafts bear several probable factors contributing to their
benefits in extravasation injuries such as stem cells, growth
factors, extracellular matrix elements, and a significant vol-
ume of hydrophobic medium. So further investigations
regarding which one of these factors contribute the most
shall be conducted.
To the best of our knowledge, this is the first experiment
assessing the efficacy of fat injections in extravasation inju-
ries. One may argue that the volumizing effect of the fat
injection is a confounding factor acting as merely a diluting
agent. For this effect microfat grafts were chosen as some
degree of volume expansion should be a desired feature for
controlling desiccant leak. The effects exclusive to fat graft
was tested in comparison to equivalent volume of saline to
eliminate dissipative effects of volume injection. These
exclusive factors may be contributed to the regenerative
properties of the fat grafts. Regenerative medicine studies
regarding fat grafts used to focus on stromal vascular frac-
tion and mesenchymal (adipose derived) stem cells [52–55].
Adipose tissue has the advantage of easy access to stem
cell compared to bone marrow, skin, and tendon [53].
Moreover, recent studies showed that adipose derived stem
cells, preadipocytes, or adipocytes are capable of secreting
an array of growth factors including hepatocyte growth
factor (HGF), vascular endothelial growth factor (VEGF),
transforming growth factor-β (TGF-β), insulin-like growth
factor (IGF)-1, basic fibroblast growth factor (bFGF),
granulocyte-macrophage colony stimulating factor (GM-
CSF) among others [56].
In conclusion, our study clearly shows that following
infiltration with a vesicant agent, fat injections are superior
to both wait-and-see and volume dilution methods in terms
of necrosis area, as well as histopathological findings, and
resultant epidermal thickness in rats. Nevertheless, further
experiments comparing fat injections to fenestration and
saline flushing; preferably with a longer follow up to better
underline the regenerative effects of fat injections should
be conducted. Future studies may involve other vesicants,
possibly with a longer follow up to compare structural and
ultrastructural properties of healed tissues. We think that
fat injections in the setting of extravasation is a safe,
cost-effective, and easy to perform procedure that can easily
be translated to clinical setting.
Disclosure statement
No potential conict of interest was reported by the author(s).
ORCID
Yigit Uyanikgil http://orcid.org/http://orcid.org/0000-0002-4016-0522
Emel Oyku Cetin http://orcid.org/http://orcid.org/0000-0001-8822-9130
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