Ostomy creation is a surgical procedure that has a major effect on patients’ lifestyle. Patients regularly1,2 report reduced quality of life and physical and psychosocial well-being in addition to the burden of ostomy care, particularly when experiencing leakage. Chronic skin irritation results in pain and discomfort, limiting daily activities and engagement in social settings and contributing to social isolation.1,2 In a nationwide survey1 of 783 patients with a permanent ileostomy, 72% reported adverse effects on daily life because of their stoma; specifically, stoma care problems, including parastomal hernia, stenosis, and prolapse, affected quality of life in 63% of patients. In a 2013 review of the literature, Kwiatt and Kawata2 found overall complication rates for all types of stomas to vary between 10% and 82%, with peristomal skin problems the most common source of patient dissatisfaction and reason for wound management nursing intervention. Musculoskeletal comorbidities (rheumatoid/osteoarthritis), immobility, poor American Society of Anesthesiologist rating, and surgery for cancer have been found to be independent risk factors for overall ostomy surgery complications; in addition, obesity contributes to poor outcomes, and respiratory comorbidities, smoking, diabetes, and malignancy associated with the highest risk of complications.2
Skin complications. Skin complications following stoma creation are common. A prospective group analysis by Persson et al3 that followed 180 patients for 2 years found a 41.2% incidence of peristomal skin complications; subgroup analysis showed persons with an ileostomy had the highest rate of skin complications (66.5%). An open-label, multinational trial by Meisner et al4 involving 3015 patients with a stoma found 57.7% had peristomal skin complications that included irritant dermatitis, mechanical trauma, infection, allergic reaction, and disease-related issues.
Irritant dermatitis. A review of stomal dermatology by Alvey and Beck5 described peristomal complications in further detail. Irritant dermatitis involves the breakdown of the most superficial layers of the skin due to the effluent that comes from the stoma, stool, or urine. This generally occurs within months of stoma formation (ie, an early complication). If not addressed, irritant dermatitis can incite local inflammation, which can inhibit stoma healing in general and lead to further effluent leakage. The drainage from ileostomies is particularly caustic and is the likely explanation as to why these stomas have a higher rate of complications.
Mechanical trauma. Mechanical trauma is a result of repeated removal and reapplication of ostomy devices; it typically occurs as a post ostomy month- to year-range complication.5 Mechanical trauma can peel off the superficial layers of the skin, causing damage and inflammation. Constant pressure of the device against the skin also can cause breakdown and the eventual development of an ulcer.5
Allergy. Allergic reactions to adhesives can occur. These reactions are not common and, due to newer adhesives, these reactions are becoming more infrequent.5
Infection. Infection-related complications can occur at any time in a patient with a stoma. The most common infectious agent is Candida albicans, but folliculitis due to Staphylococcus aureus can occur as well.5 An uncommon but often reviewed disease-related complication is pyoderma gangrenosum, defined as an ulcer with a distinct violaceous border. This type of ulcer is considered a late skin complication, occurring many years after the formation of the stoma2; it has an 0.6% incidence for ostomies overall.2 Pyoderma gangrenosum has no diabetic, venous, or pressure etiology; it is thought that disease processes such as inflammatory bowel disease may contribute to ulcer formation owing to the fact that patients with stomas created due to Crohn’s disease have an increased incidence (3.8%).2
Contour. Contour irregularities around the stoma may impair appliance fit and duration of adherence. Multiple etiologies may contribute to this, including preexisting abdominal skin rolls and poor scar formation of midline incisions that distort tissue proximal to the stoma. Additionally, patients may experience parastomal herniation, stomal retraction, and prolapse, which also can cause peristomal skin irregularities.6
Herniation. The incidence of parastomal herniation (PH), a type of incisional hernia, has been reported to range from 14.1% to 40% in persons with ileostomies.2 Herniation does not only cause contour problems; a hernia can become a surgical emergency if the contents of the hernia sac become incarcerated or (worse) strangulated. Current treatment options for PH involve surgery and include tissue repair, stoma relocation, and repair with mesh.2 Unfortunately, these options do not guarantee good outcomes; recurrence rates of 46% to 100%, 24% to 40%, and 6.9% to 17.8%, respectively, have been reported.2
Prolapse. Stomal prolapse has a general incidence in ostomies of 2% to 22%; it occurs in approximately 2% of ileostomies² and can be treated medically or surgically. Common medical options are usually aimed at reducing bowel edema and include manual reduction, use of topical table sugar, and hyaluronidase injection; surgical options include local repair with stapler devices.2 No studies have assessed the long-term effectiveness of these techniques.
Retraction. Stomal retraction alters the skin and affects ostomy device fit. Researchers and clinicians do not agree whether to categorize stomal retraction as an early or late complication, but the overall incidence (ie, for all ostomy types) for this complication is 32.2% to 40.1%.2 Stomal retraction increases the chances of stoma leakage, leading to skin-related complications. Because a common underlying cause is increased tension on the bowel, most treatments attempt to reduce this tension, usually by surgery.2 Successful repair is not always possible through the ostomy opening; a laparotomy often is necessary, which brings its own complications and compounds the chances of a negative outcome for the patient.2
Fat grafting. Fat grafting involves harvesting adipose tissue via a cannula for injection into other sites and has been found to be an effective and reliable tool, used extensively in reconstructive and aesthetic plastic surgery to correct volume deficits and augment soft tissues and contour. It has been described in multiple reviews and randomized clinical trials7-11 to aid in the reconstruction of the breast, extremities, and craniofacial areas, and reports of its safety have been published extensively. A recent literature review by Simonacci et al9 found the overall complication rate for fat grafting in breast reconstruction to be 8.4%. A prospective, randomized study that compared fat grafting for pedal fat pad atrophy to supportive care in 25 patients found persons who underwent fat grafting had significantly reduced pain and improved foot function as compared with the supportive care group.11
Fat grafting to improve peristomal contour irregularity and consequently appliance fit appears to be effective with low morbidity and minimal down time.12 Fewer device changes result in improved quality of life and a significant positive financial impact. A cohort study12 involving 164 patients with ostomies showed that using better fitting appliances with less leakage results in improvement of secondary skin inflammation. Although multiple fat grafting procedures may be required to achieve the desired result, this procedure is simpler and safer than further gastrointestinal surgery such as relocating the stoma, especially in patients who have had multiple prior surgical procedures. Fat grafting may be contraindicated if the patient were to have insufficient donor site adiposity; however, the vast majority of patients have sufficient tissue. Relocating the stoma may be reserved as a later option.
Because many approaches to peristomal complications and securing appliance fit come with challenges, the authors pursued fat grafting as a viable option to treat contour irregularity around the stoma in an eligible patient, thereby improving appliance fit and quality of life.