Fat Grafting to the Hand after Ulnar Nerve Repair
Ryan Hoffman, MD, David Morris, MD, and Mark Grevious, MD
Introduction: Fat grafting is commonly used to improve soft tissue contour and surface irregularities.
More specifically, fat grafting in the hand has been well described for cosmetic rejuvenation of the aging
hand and to improve the appearance of intermetacarpal wasting or arthritis 1,2. Literature of autologous
fat injections used to restore the appearance of a hand after nerve damage and repair is scarce. 3
Following injury and successful repair of the ulnar nerve, we observed an atrophied
appearance of the patient’s hand, even though the function of the hand was restored. There was
intermetacarpal and hypothenar wasting related to the ulnar nerve. In addition, there also was thenar
wasting, which was most likely due to disuse atrophy. We describe the indications, anatomic planning,
and surgical procedures that were used to reverse the wasted appearance of the hand following the ulnar
nerve injury and repair. In this context, fat grafting has yielded significant aesthetic improvement in the
appearance of the hand.
Case Report: A 21 year old male suffered knife injury to the right elbow region. He was determined to
have an ulnar nerve injury for which he underwent an immediate ulnar nerve repair (Figure 1). After
occupational therapy, the patient had a good functional outcome, but demonstrated wasting of the
intrinsic muscles.
Figure 1. Initial knife injury. Ulnar nerve transaction. Ulnar nerve repair.
An ulnar nerve lesion is characterized by wasting of the interosseus muscles, which can cause a
“guttering” of the back of the hand. It also shows wasting of the web space between thumb and index
finger. Softening and flattening of the hypothenar eminence with sparing of abductor pollicis brevis may
also occur. Our patient demonstrated these characteristics but also showed thenar wasting, which may
have been attributable to disuse atrophy during his rehabilitation. He was most disturbed by the sunken
appearance of the hypothenar eminence, the thenar eminence, and the dorsal surface of his right hand
(Figure 2).
Figure 2. Wasted dorsal surface of right hand compared to left hand.
METHOD: The patient was deemed a candidate for fat grafting to the hand. The patient was informed
that additional grafting may need to take place due to unpredictable fat resorption. The areas that
concerned the patient the most were identified preoperatively with the patient awake (Figure 3). The
Coleman method of structural fat grafting to the hand was used. The lower abdominal fat compartment
was infiltrated with tumescent solution. The fat was harvested using hand held liposuction. The
resulting mixture was centrifuged. The oil layer was decanted and the aqueous portion was drained.
The remaining 35ml of fat was transferred into a series of 2cc syringes.
Figure 3. Preoperative Markings
The fat was then injected with a blunt tip needle into the marked areas of depression. Several different
incisions were utilized in order to deposit small beads of fat in a weaving fashion. The fat was injected
until the areas were overcorrected (Figure 4). In the periphery, the fat was feathered to provide a
smooth transition to the unaffected areas. The goal of the injections was to deposit the fat grafts in the
supramuscular and the subdermal planes. After the grafts were placed, the areas were massaged to try
to even out any contour deformities. Elastic tape and a splint were applied postoperatively.
Figure 4. Fat graft harvesting and injection.
Results: The procedure was done as outpatient surgery. The patient was instructed to elevate the hand
as much as possible. The splint was maintained for one week (Figure 5). No complications were
observed. At two and six month follow up, there appears to be clinically good fat graft take (Figure 6).
The patient is extremely happy with the results and would undergo the procedure again.
Conclusion: We present a common technique applied to a less common scenario with promising
results. It has been shown that patients with traumatic nerve injuries of the hand have a higher level of
psychological stress. This higher stress can translate to a worsened functional recovery, worsened motor
recovery, decreased capacity for work, and more time off of work4. Therefore, there may be a
relationship between restoring the normal appearance of the hand and lessening the patient’s downtime.
We conclude that fat injections to the hand are a valuable adjunctive treatment for the atrophied
appearance of a hand following ulnar nerve injury and repair.
Figure 5. One week postoperative views of the hand.
Figure 6. Two month postoperative views of the hands showing symmetry.
REFERENCES
1. Coleman, Sydney R. Hand Rejuvenation with Structural Fat Grafting. Plast Reconstr Surg 110(7):17311744, 2002.
2. Carraway, James H. Hand Rejuvenation with Structural Fat Grafting by Sydney R. Coleman, M.D. Plast
Reconstr Surg 110(7):1745-1747, 2002.
3. Belmahi, Amin et al. Thinking About The Aesthetic Dimension In Dealing with the Hand Suffering From
Ulnar Nerve Palsy. ANZ Journal of Surgery 73 Supplement 2:A211, 2003.
4. Jaquet, Jean-Bart, et al. Early Psychological Stress After Forearm Nerve Injuries: A Predictor for LongTerm Functional Outcome and Return to Productivity. Annals of Plastic Surgery 49(1):82-90, 2002.
5. Plancher, Kevin D, Bishai, Shariff, M.S. Anterior Intramuscular Transposition of the Ulnar Nerve.
Techniques in Orthopaedics. 21(4):311-317, 2006.
6. Roganovic, Zoran. Missile-caused Ulnar Nerve Injuries: Outcomes of 128 Repairs. Neurosurgery
55(5):1120-1129, 2004.
7. Jacob, Anu DM, et al. Compression of the Deep Motor Branch of the Ulnar Nerve: An Unusual Cause
of Pure Motor Neuropathy and Hand Wasting. Archives of Neurology 62(5):826-827, 2005.