Fat Grafting for Lost Heel and Foot Padding After Vascular Wounds

I love this incredibly niche question, and I don't think I've ever been asked it on social media before. Most of what you see from me is about breasts and bodies, but this is a problem plastic surgeons treat on a semi-regular basis, and it deserves a real answer.

We see patients with a history of vascular disease, meaning decreased blood flow to the lower extremities, the legs and feet. For various reasons, these patients end up with wounds.

Just getting those wounds to heal can be quite a challenge on its own. But even once they heal over, many patients are left with decreased cushioning. Sometimes the skin is sitting directly on the bone.

Depending on where the wound was on the foot or ankle, that can cause two separate problems:

• Areas that actually hurt when you walk
• Areas that rub on shoes, and even clothing, which can cause new wounds

That second one is the real danger. You've fought hard to heal a wound, and now the healed area is set up to break down again.

First and foremost, anytime you're dealing with a patient who has vascular disease and wounds from it, it's really important to correct what you can.

If there are perfusion issues to the lower extremity, it's always best to get those solved before I, as a plastic surgeon, go mucking around down there. Only once we've determined that the blood supply to the area is sufficient to heal does it make sense to talk about adding padding back.

Once perfusion is adequate, my favorite option for patients with decreased padding, especially on the heel, is fat grafting.

Fat grafting is a technique we use all over the body, and it can be very powerful in this particular situation. But it only works if the fat survives, and that's why the blood supply matters so much here. Fat grafting is a true graft: the transferred fat has to pick up a new blood supply from the tissue around it, or it dies.

So making sure the area that had the wound has sufficient blood supply isn't a box to check. It's the difference between the fat taking and creating new problems. As you pointed out in your comment:

Fat grafting can work very well in this area, but you need to be careful, and it often takes more than one round.

If you have an area where the skin is directly on bone, getting back enough padding that it feels closer to normal usually means several rounds of fat grafting to gradually thicken the area up. Only a portion of the fat survives each time, which is normal for any fat graft, and it's why we build up in stages rather than trying to do it all at once.

These areas in patients with vascular disease don't heal well at baseline. And when there has already been trauma and healing in the area, they heal even worse.

So it's very common for me to use adjunctive therapies like hyperbaric oxygen therapy, both to aid the take of your fat graft and to aid your healing. It's the same tool we use to boost oxygen delivery when tissue is struggling after other surgeries.

One more thing worth knowing if you have vascular disease and are nervous about an operation: this can often be done without general anesthesia.

In my experience, this approach has had really good success with pretty low complication rates. Patients get relief from their pain, and they feel more mobile and functional.

If you've had wounds on your feet or ankles from vascular disease and they've healed but left you with little or no padding, whether that's pain when you walk or skin that keeps rubbing and breaking down, fat grafting can be a great option, especially for the heel.

The order matters:

1. Fix blood flow first. Perfusion has to be sufficient for anything to heal.
2. Graft in stages. Skin sitting on bone usually needs several rounds to build up real cushioning.
3. Support the healing. Adjuncts like hyperbaric oxygen therapy help the fat take in tissue that doesn't heal well at baseline.

Done carefully, it can take away the pain and get you moving again, often without general anesthesia.