A Closer Look At Autologous Fat Transfers To The Foot

Foot fillers are becoming more and more mainstream in today’s treatment armamentarium for loss of plantar cushioning and fat pad atrophy. Patients may complain of pain in the ball the foot due to trauma, metatarsalgia, collagen connective tissue diseases, autoimmune conditions, diabetes and other etiologies.While dermatologic fillers currently have Food and Drug Administration (FDA) approval for use in the face and other areas of the body, physicians are using these modalities off-label in the foot. In my experience, these fillers have been able to provide extreme relief of pain for patients.

Injection of fillers is easy to perform with the product being stored on the shelf in the office. After performing a clinical evaluation, including X-rays and discussion with the patient, one can perform a quick injection, which can provide immediate, short-term relief. Common fillers that physicians use off-label in the foot include Radiesse^® (Merz Aesthetics^®), Restylane^® (Galderma), Juvederm^® Voluma XC (Allergan), and Sculptra^® (Galderma). The downside to this treatment course is not only the cost but the limited short-term benefit of the filler. 

In an effort to find a longer-term solution, I have found that fat transfer to the foot is a promising option.

One would perform the autologous fat transfer with fat harvested from the abdomen, buttocks, inner thigh, inner knee or calf. Then the surgeon would place the fat into the high-pressure or atrophied area of the foot. Harvesting is either done by a colleague or, depending on the state scope of practice, by the podiatric surgeon. One can perform this procedure in the office or in an outpatient setting with the patient having a local anesthetic. If operating in conjunction with a plastic surgeon, the team can perform liposuction and contouring, thus addressing dual purposes in one procedure.

Typically, the harvesting surgeon ensures placement of tumescent anesthetic into a donor site and harvests the fat by manual negative pressure, using a blunt cannula attached to a syringe. Either through a centrifuge or by gravity, one separates the adipose tissue into three layers. The harvesting surgeon discards the bottom liquid layer -- containing water, the tumescent mixture and cells -- along with the top oil layer. One then employs the middle layer of good fat cells for the injection into the foot. In my experience, surgeons can enhance the longevity of the fat transfer by mixing the harvested middle layer with protein-rich plasma (PRP).

After making a stab incision to the skin with an 11-blade, use a blunt tip cannula to inject the fat into the high pressure area. For injection of the metatarsal head region, it is also advised to inject around the metatarsal neck in order to facilitate a deeper internal metatarsal pad.

Immediately the patient will feel the filler and plumping on the ball of the foot. Over time, a portion of the fat itself does resorb as well as the water portion of the transferred tissue.  It takes approximately 12 weeks to feel the full benefit of the transfer and full relief of pain.I recommend to have the patient initially use forefoot offloading shoes or post-op shoes with offloading pads.Patients can resume activity in a supportive sneaker with light activity after approximately two weeks.

When considering the use of fillers in the foot, one shouldconsider autologous fat transfer for a potentially longer-lasting and more enhanced option for patient pain relief. 

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