Treatment of painful neuromas of the upper limb has been largely debated. The current surgical treatments spare from simple neuroma excision to proximal nerve stump relocation (into muscles, veins, and bones). Perineural fat grafting consists of neuroma excision and the creation of an autologous adipose graft wrapped around the proximal nerve stump. This technique should be prescribed to those patients suffering from terminal neuromas or neuromas in which functional reconstruction is contraindicated. The effectiveness of this technique could be addressed both to the mechanical and biological properties of the fat graft. On one hand the graft creates a gliding layer and a protective barrier, thus allowing longitudinal excursion and protection against mechanical solicitations. On the other hand the autologous adipose tissue brings neoangiogenesis, modulates the inflammatory response, and avoids scar adherences. A retrospective analysis was performed on 7 neuromas in 7 patients, treated with perineural fat grafting from June 2009 to February 2010. Pain and limb functionality were measured, respectively, with a visual acuity scale and the “Disabilities of the Arm, Shoulder, and Hand score,” preoperatively and 1 year after surgery. A mean pain reduction of 23% was recorded, without relevant complications. Improvements in limb functionality were also observed through the measurement of the Disabilities of the Arm, Shoulder, and Hand score, which improved to 18%. We believe that this technique represents a valuable and versatile option in the treatment of painful neuromas of the upper limb that could be hereafter performed for pain syndromes of neuropatic origin.