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Release of Hand Contractures with the Percutaneous Aponeurotomy & Lipo-Filling (PALF) procedure: An Incisionless Regenerative Alternative to the FLAP
Roger K. Khouri, MD1, Roger K. Khouri, Jr., BS2, Eufemiano Cardoso, MD1, Kimberly S. Khouri, BS3.
1Miami Hand Center, Key Biscayne, FL, USA, 2University of Michigan School of Medicine, Ann Arbor, MI, USA, 3New York University School of Medicine, New York City, NY, USA.

PURPOSE: Needle pricks selectively cut tight structures while sparing looser neurovascular bundles. This allows a percutaneous mesh-expansion of hand contractures, while subsequent seeding the mesh interspaces with fat grafts regenerates the gaps. We present our 10-year experience with Percutaneous Aponeurotomy and Lipo-Filling (PALF) an alternative to flaps for hand contractures.
METHODS: With the contractures under tension, we percutaneously generate a pattern of 1.2-mm slits that mesh-expand the contracture and then seed the generated scaffold with liposuctioned fat grafts. The hand is immobilized in extension for 5-7 days before returning to gentle activities.
RESULTS: We performed 246 PALF procedures (202 Dupuytren, 44 scar contractures) on 200 patients. No incisions or sutures were required. Patients had a quick recovery; 90% returned to gentle activities within 8 days. Dupuytren treatment yielded 110% and 57% correction at MPJ and PIPJ at 12 months (comparable to open fasciectomy and flap.) PALF-treated areas resulted in 30% tissue gain, allowing for incisionless release of contractures that would have otherwise required flap surgery. There was no nerve injury. Complications were infrequent and minimal.
CONCLUSION: 1-mm needle pricks leave no scars; the sum of staggered slits can expand the overall meshed area by 20-30%. Fat grafting the tiny interspaces fills the gap with near-normal tissue, thus regenerating the tissue deficiency without scar or donor defect. Our experience shows that PALF is an incisionless, regenerative alternative to flaps.


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