The serial free fat transfer in irradiated prosthetic breast reconstructions

Comparing Costs: Does Extreme Oncoplastic Breast-Conserving Surgery Confer a Cost Benefit When Compared with Mastectomy and Reconstruction?

INTRODUCTION

Extreme oncoplastic breast-conserving surgery (eOBCS) describes the application of OBCS to patients who would otherwise need a mastectomy, and its safety has been previously described.

OBJECTIVE

We aimed to compare the costs of eOBCS and mastectomy.

METHODS

We reviewed our institutional database to identify breast cancer patients treated surgically from 2018 to 2023. We included patients with a large disease span (≥5 cm) and multifocal/multicentric disease. Patients were grouped by their surgical approach, i.e. eOBCS or mastectomy. The direct costs of care were determined and compared; however, indirect costs were not included.

RESULTS

Eighty-six patients met the inclusion criteria, 10 (11.6%) of whom underwent mastectomy and 76 (88.4%) who underwent eOBCS. Six mastectomy patients (60%) had reconstruction and 6 (60%) underwent external beam radiation therapy (EBRT). Reconstructions were completed in a staged fashion, and the mean cost of the index operation (mastectomy and tissue expander) was $17,816. These patients had one to three subsequent surgeries to complete their reconstruction, at a mean cost of $45,904. The mean cost of EBRT was $5542. Thirty-four eOBCS patients (44.7%) underwent 44 margin re-excisions, including 6 (7.9%) who underwent mastectomy. Sixty (78.9%) of the eOBCS patients had EBRT. The mean cost of their index operation was $6345; the mean cost of a re-excision was $3615; the mean cost of their mastectomies with reconstruction was $49,400; and the mean cost of EBRT was $6807. The cost of care for eOBCS patients remained lower than that for mastectomy patients, i.e. $17,318 versus $57,416.

CONCLUSION

eOBCS is associated with a lower cost than mastectomy and had a low conversion rate to mastectomy.

Autologous fat transplantation prior to permanent expander implant breast reconstruction enhances the outcome after two years: a randomized controlled trial

Radiotherapy is important in breast cancer treatment. A side effect of the treatment is fibrosis that decreases the possibility for a successful breast reconstruction with expanders and with high patient satisfaction with the result. The most common option for mastectomized, irradiated women wishing for a breast reconstruction is autologous tissue transplantation. However, some patients are not suitable for flap surgery. Fifty mastectomized and irradiated women were included in a randomized controlled trial. They underwent breast reconstruction with expanders and were allocated 1:1 to either receive pre-treatment with autologous fat transplantation (AFT) or not. Primary outcomes were frequency of reoperations and complications. Secondary outcomes were number of days in hospital, number of outpatient visits to surgeon or nurse and patient reported outcome as reported with Breast Q. Follow-up time was 2 years. Fifty-two per cent of the intervention group and 68% of the controls underwent reoperations (p = 0.611). Thirty-two per cent of the intervention group and 52% of the controls had complications (p = 0.347). The median number of consultations with the nurse was four in the intervention group and six in the control group (p = 0.002). The AFT patients were significantly more satisfied with their breasts and psychosocial well-being after 2 years. They also had higher increase in satisfaction with breasts, psychosocial well-being, and sexual well-being when comparing baseline with 2 years postoperatively. This randomized controlled trial indicates benefits of AFT prior to breast reconstruction with expanders, especially on patient reported outcome even if the study sample is small.

Adipose-Derived Stromal Cell-Based Therapies for Radiation-Induced Fibrosis

Significance: Half of all cancer patients receive radiation therapy as a component of their treatment regimen, and the most common resulting complication is radiation-induced fibrosis (RIF) of the skin and soft tissue. This thickening of the dermis paired with decreased vascularity results in functional limitations and esthetic concerns and poses unique challenges when considering surgical exploration or reconstruction. Existing therapeutic options for RIF of the skin are limited both in scope and efficacy. Cell-based therapies have emerged as a promising means of utilizing regenerative cell populations to improve both functional and esthetic outcomes, and even as prophylaxis for RIF. Recent Advances: As one of the leading areas of cell-based therapy research, adipose-derived stromal cells (ADSCs) demonstrate significant therapeutic potential in the treatment of RIF. The introduction of the ADSC-augmented fat graft has shown clinical utility. Recent research dedicated to characterizing specific ADSC subpopulations points toward further granularity in understanding of the mechanisms driving the well-established clinical outcomes seen with fat grafting therapy. Critical Issues: Various animal models of RIF demonstrated improved clinical outcomes following treatment with cell-based therapies, but the cellular and molecular basis underlying these effects remains poorly understood. Future Directions: Recent literature has focused on improving the efficacy of cell-based therapies, most notably through (1) augmentation of fat grafts with platelet-rich plasma and (2) the modification of expressed RNA through epitranscriptomics. For the latter, new and promising gene targets continue to be identified which have the potential to reverse the effects of fibrosis by increasing angiogenesis, decreasing inflammation, and promoting adipogenesis.

The Efficacy of Fat Grafting on Treating Post-Mastectomy Pain with and without Breast Reconstruction: A Systematic Review and Meta-Analysis

Post-mastectomy pain syndrome (PMPS), characterized by persistent pain lasting at least three months following mastectomy, affects 20-50% of breast surgery patients, lacking effective treatment options. A review was conducted utilizing EMBASE, MEDLINE, and all evidence-based medicine reviews to evaluate the effect of fat grafting as a treatment option for PMPS from database inception to 29 April 2023 (PROSPERO ID: CRD42023422627). Nine studies and 812 patients in total were included in the review. The overall mean change in visual analog scale (VAS) was -3.6 in 285 patients following fat grafting and 0.5 in 147 control group patients. There was a significant reduction in VAS from baseline in the fat grafting group compared to the control group, n = 395, mean difference = -2.17 (95% CI, -2.95 to -1.39). This significant improvement was also noted in patients who underwent mastectomy without reconstruction. Common complications related to fat grafting include capsular contracture, seroma, hematoma, and infection. Surgeons should consider fat grafting as a treatment option for PMPS. However, future research is needed to substantiate this evidence and to identify timing, volume of fat grafting, and which patient cohort will benefit the most.

Scarring and Skin Fibrosis Reversal with Regenerative Surgery and Stem Cell Therapy

Skin scarring and fibrosis affect millions of people worldwide, representing a serious clinical problem causing physical and psychological challenges for patients. Stem cell therapy and regenerative surgery represent a new area of treatment focused on promoting the body's natural ability to repair damaged tissue. Adipose-derived stem cells (ASCs) represent an optimal choice for practical regenerative medicine due to their abundance, autologous tissue origin, non-immunogenicity, and ease of access with minimal morbidity for patients. This review of the literature explores the current body of evidence around the use of ASCs-based regenerative strategies for the treatment of scarring and skin fibrosis, exploring the different surgical approaches and their application in multiple fibrotic skin conditions. Human, animal, and in vitro studies demonstrate that ASCs present potentialities in modifying scar tissue and fibrosis by suppressing extracellular matrix (ECM) synthesis and promoting the degradation of their constituents. Through softening skin fibrosis, function and overall quality of life may be considerably enhanced in different patient cohorts presenting with scar-related symptoms. The use of stem cell therapies for skin scar repair and regeneration represents a paradigm shift, offering potential alternative therapeutic avenues for fibrosis, a condition that currently lacks a cure.

Deconstructing Fat to Reverse Radiation Induced Soft Tissue Fibrosis

Adipose tissue is composed of a collection of cells with valuable structural and regenerative function. Taken as an autologous graft, these cells can be used to address soft tissue defects and irregularities, while also providing a reparative effect on the surrounding tissues. Adipose-derived stem or stromal cells are primarily responsible for this regenerative effect through direct differentiation into native cells and via secretion of numerous growth factors and cytokines that stimulate angiogenesis and disrupt pro-inflammatory pathways. Separating adipose tissue into its component parts, i.e., cells, scaffolds and proteins, has provided new regenerative therapies for skin and soft tissue pathology, including that resulting from radiation. Recent studies in both animal models and clinical trials have demonstrated the ability of autologous fat grafting to reverse radiation induced skin fibrosis. An improved understanding of the complex pathologic mechanism of RIF has allowed researchers to harness the specific function of the ASCs to engineer enriched fat graft constructs to improve the therapeutic effect of AFG.

The effect of radiotherapy on fat engraftment for complete breast reconstruction using lipofilling only

PURPOSE

Lipofilling has been established as a standard technique for contour enhancement following breast reconstruction. However, there is a paucity in current literature regarding the use of this technique for complete reconstruction of the female breast as an alternative to conventional techniques, such as expander or flap-based procedures. In particular, the influence of pre-operative irradiation for successful reconstruction has rarely been examined in published studies. Here, the authors describe their experience with successful fat injection in pre-radiated breasts in comparison with non-pre-radiated patients.

METHODS

In this retrospective study, we examined a total of 95 lipofilling treatments on 26 patients (28 breasts). All of them experienced mastectomy following breast cancer; local breast defects after partial resection of the gland were not included in this study. In total, 47 lipofilling procedures in 12 non-irradiated patients (14 breasts) and 48 procedures in 14 irradiated women (also 14 breasts) were performed. Per session, approximately 297 ± 112 cc of adipose tissue was grafted in group A (no radiotherapy) and approximately 259 ± 93 cc was grafted in group B (radiotherapy).

RESULTS

Among the group of women without pre-operative radiation, 71% of breast reconstructions limited to lipofilling only showed constant engraftment of fat tissue with a successful reconstructive result, whereas only 21% of the patients with pre-radiated breasts showed complete reconstruction of the breast with a permanent fat in-growth.

CONCLUSION

Preoperative radiotherapy significantly impedes successful completion of breast reconstructions planned only by autologous fat transfer. Patients should be selected individually and carefully for complete breast reconstruction using lipofilling only.

Decellularized Adipose Matrices Can Alleviate Radiation-Induced Skin Fibrosis

Objective: Radiation therapy is commonplace for cancer treatment but often results in fibrosis and atrophy of surrounding soft tissue. Decellularized adipose matrices (DAMs) have been reported to improve these soft tissue defects through the promotion of adipogenesis. These matrices are decellularized by a combination of physical, chemical, and enzymatic methods to minimize their immunologic effects while promoting their regenerative effects. In this study, we aimed at exploring the regenerative ability of a DAM (renuva®; MTF biologics, Edison, NJ) in radiation-induced soft tissue injury. Approach: Fresh human lipoaspirate or DAM was injected into the irradiated scalp of CD-1 nude mice, and volume retention was monitored radiographically over 8 weeks. Explanted grafts were histologically assessed, and overlying skin was examined histologically and biomechanically. Irradiated human skin was also evaluated from patients after fat grafting or DAM injection. However, integrating data between murine and human skin in all cohorts is limited given the genetic variability between the two species. Results: Volume retention was found to be greater with fat grafts, though DAM retention was, nonetheless, appreciated at irradiated sites. Improvement in both mouse and human irradiated skin overlying fat and DAM grafts was observed in terms of biomechanical stiffness, dermal thickness, collagen density, collagen fiber networks, and skin vascularity. Innovation: This is the first demonstration of the use of DAMs for augmenting the regenerative potential of irradiated mouse and human skin. Conclusions: These findings support the use of DAMs to address soft tissue atrophy after radiation therapy. Morphological characteristics of the irradiated skin can also be improved with DAM grafting.

Implant-Based Breast Reconstruction after Mastectomy, from the Subpectoral to the Prepectoral Approach: An Evidence-Based Change of Mind?

Over the last years, prepectoral implant-based breast reconstruction has undergone a renaissance due to several technical advancements regarding mastectomy techniques and surgical approaches for the placement and soft tissue coverage of silicone implants. Initially abandoned due to the high incidence of complications, such as capsular contraction, implant extrusion, and poor aesthetic outcome, the effective prevention of these types of complications led to the prepectoral technique coming back in style for the ease of implant placement and the conservation of the pectoralis muscle function. Additional advantages such as a decrease of postoperative pain, animation deformity, and operative time contribute to the steady gain in popularity. This review aims to summarize the factors influencing the trend towards prepectoral implant-based breast reconstruction and to discuss the challenges and prospects related to this operative approach.

Fat Grafting before Delayed Prophylactic Mastectomy and Immediate Implant Reconstruction for Patients at High Risk of Complications

SUMMARY

The majority of patients undergoing bilateral prophylactic mastectomy request immediate implant-based breast reconstruction. Some patients, especially those with prior radiotherapy, are at increased risk of early cutaneous complications and implant loss. The authors developed the technique of primary fat grafting before delayed prophylactic mastectomy to minimize early complications for selective high-risk patients. They have completed 21 cases in 14 patients, 10 of whom had previous lumpectomy and radiation treatment for breast cancer. A single session of fat grafting, with a median injection volume of 250 ml (interquartile range, 200 to 300 ml), was performed a median period of 19 weeks (interquartile range, 16 to 28 weeks) before prophylactic mastectomy. All cases were direct-to-implant reconstruction using textured silicone implants. The median implant volume was 410 ml (interquartile range, 318 to 450 ml). A minor early complication developed in 14 percent of cases (three of 21), with no early implant loss. At a median follow-up of 9 months (interquartile range, 5 to 27 months), the authors found no cases of implant loss and an excellent or good aesthetic outcome (score of 5 or 4) in 16 of 21 cases (76 percent). Fat grafting before prophylactic mastectomy is a novel strategy to minimize early complications and avoid implant loss in patients at high risk of postoperative complications. .

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Punctual Breast Implant Rupture following Lipofilling: Only a Myth?

Background

Lipofilling techniques are widespread in clinical practice as a complement to breast reconstruction, despite posing some risk. Punctual implant rupture following a fat transfer is one of the possible complications, which has not been properly reported yet and is probably being underdiagnosed. The aim of this paper is to report key facts for appropriate diagnosis of this clinical chart.

Case Report

We present the case of a 47-year-old woman with a bilateral prosthetic breast reconstruction who was treated with autologous fat graft for upper pole enhancing and scar improvement. The patient developed an early unilateral breast capsular contracture after the fat graft procedure, with normal radiological exploration. Surgical findings showed intraprosthetic fat deposits and a punctual implant rupture.

Conclusions

Punctual breast implant rupture is a possible complication of lipofilling that is usually not suspected at first consultation and might be underdiagnosed based on radiological findings, so investigating clinical signs should necessarily be a prerequisite to diagnosis.

The role of fat grafting on contracted breast implant capsules: A retrospective comparative histological and immunohistochemical study

Capsular contracture, a common complication of breast implant reconstruction following postmastectomy radiotherapy (PMRT), represents a challenge for plastic surgeons. Regenerative surgery with multiple autologous fat grafts (lipobed) before replacing the implant has been proven to be a satisfactory approach in the radio-damaged breast. Currently, in literature, there are no data available on the histological features of irradiated capsules after regenerative surgery. We enrolled 80 patients after immediate subpectoral alloplastic breast reconstruction, with indication for revision surgery due to grade IV capsular contracture developed after PMRT. Forty patients were undergoing multiple fat grafting (lipobed group, mean age 48) and 40 patients were not undergoing multiple fat grafting (non-regenerative surgery (NRS) group, mean age 49). The removed capsules were addressed to histological and immunohistochemical assessment. The capsules of the lipobed group patients compared with NRS group patients showed: a lower mean thickness (602.17 versus 670.43 µm; P = 0.013), a lower collagen fiber alignment (median value of angle deviation: 30.34 versus 18.38; P = 0.001), a lower immunohistochemical positivity for myofibroblasts (α-smooth muscle actin [α-SMA] expression: 12.5% versus 52.5%; P = 0.00), a higher immunohistochemical positivity for estrogen receptor-β (ER-β; 80% versus 20%; P = 0.00), and a lower immunohistochemical positivity for estrogen receptor-α (ER-α; 53.3% versus 16.7%; P = 0.00). The histological and immunohistochemical differences found are possibly due to alterations in the extracellular microenvironment determined by grafted fat.

Radiation-Induced Tissue Damage: Clinical Consequences and Current Treatment Options

Radiation therapy is a valuable tool in the treatment of numerous malignancies but, in certain cases, can also causes significant acute and chronic damage to noncancerous neighboring tissues. This review focuses on the pathophysiology of radiation-induced damage and the clinical implications it has for plastic surgeons across breast reconstruction, osteoradionecrosis, radiation-induced skin cancers, and wound healing. The current understanding of treatment modalities presented here include hyperbaric oxygen therapy, autologous fat grafting and stem cells, and pharmaceutical agents.

Adipose-derived stromal cells for nonhealing wounds: Emerging opportunities and challenges

Wound healing complications affect thousands of people each year, thus constituting a profound economic and medical burden. Chronic wounds are a highly complex problem that usually affects elderly patients as well as patients with comorbidities such as diabetes, cancer (surgery, radiotherapy/chemotherapy) or autoimmune diseases. Currently available methods of their treatment are not fully effective, so new solutions are constantly being sought. Cell-based therapies seem to have great potential for use in stimulating wound healing. In recent years, much effort has been focused on characterizing of adipose-derived mesenchymal stromal cells (AD-MSCs) and evaluating their clinical use in regenerative medicine and other medical fields. These cells are easily obtained in large amounts from adipose tissue and show a high proregenerative potential, mainly through paracrine activities. In this review, the process of healing acute and nonhealing (chronic) wounds is detailed, with a special attention paid to the wounds of patients with diabetes and cancer. In addition, the methods and technical aspects of AD-MSCs isolation, culture and transplantation in chronic wounds are described, and the characteristics, genetic stability and role of AD-MSCs in wound healing are also summarized. The biological properties of AD-MSCs isolated from subcutaneous and visceral adipose tissue are compared. Additionally, methods to increase their therapeutic potential as well as factors that may affect their biological functions are summarized. Finally, their therapeutic potential in the treatment of diabetic and oncological wounds is also discussed.

Autologous Fat Grafting for Oncologic Patients: A Literature Review

Autologous fat grafting (AFG) serves as an effective method to address volume defects, contour irregularities, and asymmetry in both aesthetic and reconstructive procedures. In recent years, there has been growing concern about the potential of cancer recurrence and interference with cancer surveillance in oncologic patients receiving AFG. The adipose tissue contains adipose-derived stem cells (ASCs), a specific type of mesenchymal stem cells, that facilitate secretion of numerous growth factors which in turn stimulate tissue regeneration and angiogenesis. As such, it has been theorized that ASCs may also have the potential to stimulate cancer cell proliferation and growth when used in oncologic patients. Multiple research studies have demonstrated the ability of ACSs to facilitate tumor proliferation in animal models. However, clinical research in oncologic patients has yielded contradictory findings. Although the literature pertaining to oncologic safety in head and neck, as well as sarcoma, cancer patients remains limited, studies demonstrate no increased risk of tumor recurrence in these patient populations receiving AFG. Similarly, both the efficacy and safety of AFG have been well established in breast cancer patients through numerous clinical studies. More recently, preclinical research in animal models has shown that AFG has the potential to facilitate tissue regeneration and improve joint contracture following irradiation. Ultimately, further research is needed to elucidate the safety of AFG in a variety of oncologic patients, as well as explore its use in tissue regeneration, particularly in the setting of radiotherapy. Level of Evidence: 4.

Safety and Effectiveness of Autologous Fat Grafting after Breast Radiotherapy: A Systematic Review and Meta-Analysis

BACKGROUND

The purpose of this study was to evaluate the safety and effectiveness of autologous fat grafting after radiotherapy.

METHODS

All studies published before December of 2019 were collected by searching on PubMed, Embase, Cochrane, Web of Science, China National Knowledge Infrastructure, and Wanfang Data. After independently screening the studies and extracting the data, Stata was applied to perform meta-analysis.

RESULTS

Seventeen qualified articles were eventually included, involving a total of 1658 patients, of which 1555 underwent autologous fat grafting. Overall, empirically from the data, the use of autologous fat grafting after radiotherapy does not increase the incidence of complications or the risk of tumor recurrence. Through statistical analysis, the authors found that 152 patients suffered complications after undergoing autologous fat grafting [152 of 1555 (9.8 percent)]; 72 patients suffered complications after undergoing postradiotherapy autologous fat grafting [72 of 1040 (6.9 percent)], including seven cases of tumor recurrence [seven of 1040 (0.7 percent)]; and 80 patients suffered complications after undergoing autologous fat grafting without radiotherapy [80 of 515 (15.5 percent)], including seven cases of tumor recurrence [seven of 515 (1.4 percent)]. The authors also found that 970 of 1040 patients (93.3 percent) were satisfied with the results of postradiotherapy autologous fat grafting for breast reconstruction.

CONCLUSIONS

This study has provided an evidence-based conclusion supporting the use of autologous fat grafting for breast reconstruction after radiotherapy. Autologous fat grafting can effectively correct breast deformity and contracture caused by breast-conserving therapy and radiotherapy and increase patient satisfaction without increasing the rate of tumor recurrence.

Lipofilling in Breast Oncological Surgery: A Safe Opportunity or Risk for Cancer Recurrence?

Lipofilling (LF) is a largely employed technique in reconstructive and esthetic breast surgery. Over the years, it has demonstrated to be extremely useful for treatment of soft tissue defects after demolitive or conservative breast cancer surgery and different procedures have been developed to improve the survival of transplanted fat graft. The regenerative potential of LF is attributed to the multipotent stem cells found in large quantity in adipose tissue. However, a growing body of pre-clinical evidence shows that adipocytes and adipose-derived stromal cells may have pro-tumorigenic potential. Despite no clear indication from clinical studies has demonstrated an increased risk of cancer recurrence upon LF, these observations challenge the oncologic safety of the procedure. This review aims to provide an updated overview of both the clinical and the pre-clinical indications to the suitability and safety of LF in breast oncological surgery. Cellular and molecular players in the crosstalk between adipose tissue and cancer are described, and heterogeneous contradictory results are discussed, highlighting that important issues still remain to be solved to get a clear understanding of LF safety in breast cancer patients.

Fat Grafting in Radiation-Induced Soft-Tissue Injury: A Narrative Review of the Clinical Evidence and Implications for Future Studies

SUMMARY

Radiation-induced changes in skin and soft tissue result in significant cosmetic and functional impairment with subsequent decrease in quality of life. Fat grafting has emerged as a therapy for radiation-induced soft-tissue injury, and this narrative review aims to evaluate the current clinical evidence regarding its efficacy. A review was conducted to examine the current clinical evidence of fat grafting as a therapy for radiation-induced injury to the skin and soft tissue and to outline the clinical outcomes that can be used to more consistently quantify chronic radiation-induced injury in future clinical studies. The current clinical evidence regarding the efficacy of fat grafting to treat radiation-induced injury of the skin and soft tissue suggests that fat grafting increases skin softness and pliability, induces volume restoration, improves hair growth in areas of alopecia, reduces pain, and improves cosmetic and functional outcomes. However, literature in this field is far from robust and mired by the retrospective nature of the studies, lack of adequate controls, and inherent limitations of small case series and cohorts. A series of actions have been identified to strengthen future clinical data, including the need for physical examination using a validated scale, appropriate imaging, skin biomechanics and microcirculation testing, and histologic analysis. In conclusion, radiation-induced soft-tissue injury is a significant health burden that can lead to severe functional and aesthetic sequelae. Although still in a preliminary research phase, there is promising clinical evidence demonstrating the benefits of fat grafting to treat chronic changes after radiation therapy. Future clinical studies will require larger cohorts, adequate controls, and consistent use of objective measurements.

The Impact of Human Lipoaspirate and Adipose Tissue-Derived Stem Cells Contact Culture on Breast Cancer Cells: Implications in Breast Reconstruction

BACKGROUND

Autologous fat transfer in the form of lipoaspirates for the reconstruction of the breast after breast cancer surgery is a commonly used procedure in plastic surgery. However, concerns regarding the oncologic risk of nutrient-rich fat tissue are widely debated. Previous studies have primarily focused on studying the interaction between adipose-derived stem cells (ASCs) and breast cancer cells.

METHODS

In this study, we performed a comprehensive analysis of the paracrine- and contact-based interactions between lipoaspirates, ASCs and breast cancer cell lines. An inverted flask culture method was used to study the contact-based interaction between lipoaspirates and breast cancer cells, while GFP-expressing breast cancer cell lines were generated to study the cell-cell contact interaction with ASCs. Three different human breast cancer cell lines, MCF-7, MDA-MB-231 and BT-474, were studied. We analyzed the impact of these interactions on the proliferation, cell cycle and epithelial-to-mesenchymal (EMT) transition of the breast cancer cells.

RESULTS

Our results revealed that both lipoaspirates and ASCs do not increase the proliferation rate of the breast cancer cells either through paracrine- or contact-dependent interactions. We observed that lipoaspirates selectively inhibit the proliferation of MCF-7 cells in contact co-culture, driven by the retinoblastoma (Rb) protein activity mediating cell cycle arrest. Additionally, ASCs inhibited MDA-MB-231 breast cancer cell proliferation in cell-cell contact-dependent interactions. Quantitative real-time PCR revealed no significant increase in the EMT-related genes in breast cancer cells upon co-culture with ASCs.

CONCLUSION

In conclusion, this study provides evidence of the non-oncogenic character of lipoaspirates and supports the safety of clinical fat grafting in breast reconstruction after oncological surgical procedures. In vivo studies in appropriate animal models and long-term post-operative clinical data from patients are essential to reach the final safety recommendations.

Breast Implants for Mammaplasty: An Umbrella Review of Meta-analyses of Multiple Complications

BACKGROUND

The association of breast implants and complications after mammaplasty has been extensively researched. The aim of this study is to summarize all available results in meta-analysis investigating the association between implants and the incidence of various complications.

METHODS

An umbrella review for breast implants and associated complications was performed by searching related reviews from electronic databases including Pubmed, Ovid and CINAHL. We collected and reviewed evidence across meta-analyses of observational and interventional studies of implants and any health outcome. The quality of the reviews was assessed using the AMSTAR tool (A measurement tool to assess systematic reviews).

RESULTS

The research included 92 meta-analyses of 609 studies concerning various areas. Capsular contracture was the most investigated outcome. Radiotherapy, human acellular dermal matrix application, direct-to-implant reconstruction, smooth implant, silicone-filled implant and periareolar incision were significantly associated with higher rates of some of the complications.

CONCLUSIONS

This umbrella review provides surgeons with summarized evidence of the association between the complications and implant-related factors in mammaplasty surgery to help surgeons make informed choices in the future.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Multiple polyurethane implant punctures during fat grafting: case report and review of the literature

BACKGROUND

Breast augmentation with implants continues to be the most popular aesthetic surgical procedure performed worldwide. Fat grafting may improve the results of breast augmentation and breast reconstruction with implants. However, fat grafting to the breast with implants carries the risk of implant puncture. To our best knowledge this is the first case in which polyurethane implant puncture during fat grafting is described.

CASE PRESENTATION

We report multiple bilateral implant punctures with the cannula during fat grafting in a patient who previously underwent breast reconstruction with polyurethane implants.

CONCLUSIONS

Implants that promote tissue ingrowth may be more prone to puncture with the cannula during fat grafting. Specific planning and surgical maneuvers decrease the risk of implant puncture.

LEVEL OF EVIDENCE

Level V, case report.

Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast

Radiation therapy is frequently a critical component of breast cancer care but carries with it side effects that are particularly damaging to reconstructive efforts. Autologous lipotransfer has the ability to improve radiated skin throughout the body due to the pluripotent stem cells and multiple growth factors transferred therein. The oncologic safety of lipotransfer to the breasts is demonstrated in the literature and is frequently considered an adjunctive procedure for improving the aesthetic outcomes of breast reconstruction. Using lipotransfer as an integral rather than adjunctive step in the reconstructive process for breast cancer patients requiring radiation results in improved complication rates equivalent to those of nonradiated breasts, expanding options in these otherwise complicated cases. Herein, we provide a detailed review of the cellular toxicity conferred by radiotherapy and describe at length our approach to autologous lipotransfer in radiated breasts.

The effect of hyperbaric oxygen treatment on late radiation tissue injury after breast cancer: A case-series of 67 patients

INTRODUCTION

Late radiation tissue injury (LRTI) after breast cancer may benefit from hyperbaric oxygen treatment (HBOT). This study aimed to report the LRTI symptom scores up to 12 months after HBOT and identify risk factors for poor scores.

METHODS

A case-series of 67 patients who underwent a mean of 44 sessions of HBOT was analysed. LRTI symptoms were scored at four time points using the LENT-SOMA scale (Late Effects in Normal Tissues - Subjective, Objective, Management, and Analytic), a visual analog scale for pain, and the range of shoulder motion.

RESULTS

Between starting HBOT and 12 months after HBOT 57 patients (85%) reported at least one point improvement in their LENT-SOMA score. Median pain and fibrosis scores improved significantly between the start and end of HBOT (P < 0.001), and remained stable three and 12 months after HBOT. The median breast oedema score improved significantly 12 months after HBOT (P = 0.003). Median shoulder abduction increased significantly from 90 to 165 degrees (P = 0.001) and median shoulder anteflexion increased significantly from 115 to 150 degrees (P = 0.004). Various risk factors were identified for poor scores despite HBOT; the most common risk factor was a poor score at start of HBOT.

CONCLUSIONS

In this case-series, patients who underwent HBOT for LRTI after breast cancer reported significant improvement in pain, fibrosis, oedema, and shoulder movement. The improvement persisted up to 12 months after HBOT. A poor score at the start of HBOT was predictive for a poor score 12 months after HBOT.

Effects of Prophylactic Lipofilling After Radiotherapy Compared to Non-Fat Injected Breasts: A Randomized, Objective Study

BACKGROUND

Patients who are suffering from invasive breast cancer may require post-mastectomy radiation therapy (PMRT). PMRT improves outcomes in breast cancer patients in terms of locoregional recurrence. Preliminary studies indicate that fat injections reduce post-radiation damage of soft tissue and implants.

OBJECTIVES

The aim of this study was to demonstrate the safety and effectiveness of prophylactic fat injections on radiated implanted breasts.

METHODS

The authors randomly assigned 60 female patients to either Group A or B. Group A patients received 3 breast fat injections, according to Coleman's technique, after radiotherapy and before expander removal with definitive implant insertion. Group B patients underwent surgery without lipofilling. At each surgical operation, skin biopsies were performed in a specific breast area to evaluate adipose tissue thickness, and a statistical analysis of the thickness variations was performed with the Wilcoxon's sum test. Disability was assessed according to the Late Effects of Normal Tissues-Subjective Objective Management Analytic scale.

RESULTS

The study demonstrates a qualitative and quantitative improvement about tissues after fat injection. This is highlighted by the significant increase in thickness after lipofilling.

CONCLUSIONS

The study, which is based on both clinical and histological findings and is supported by the comparison of a control group with a 1-year follow-up, demonstrates that fat injections reduce tissue radio damage, improving reconstructive surgery outcomes and quality of life.

LEVEL OF EVIDENCE: 2

Autologous fat transfer to treat fibrosis and scar-related conditions: A systematic review and meta-analysis

BACKGROUND

Autologous fat transfer (AFT), also known as lipofilling, has been demonstrated to be more than just a filler. Through both mechanical dissection and local tissue remodelling mediated by stem cells, it is thought to improve scar quality, function and even pain. This paper aims to investigate the evidence regarding its safety and effectiveness for treating fibrosis and scar-related conditions.

METHODS

A literature search was performed in PubMed, Embase and the Cochrane Library to identify relevant studies. Extensive data extraction and standardization allowed conducting a meta-analysis.

RESULTS

Forty-five studies (3033 patients) provided sufficient data for meta-analysis. The AFT treatment resulted in significant increase in satisfaction scores of both patient and surgeon (p  =  0.001). Furthermore, a significant overall scar improvement was also found in the evaluation using the Patient and Observer Scar Assessment Scale, with the most notable effect in the scar stiffness (p<0.001) and pliability (p  =  0.004). In patients with severe pain, AFT resulted in a significant pain reduction of 3.7 points on the Visual Analogue Scale (p<0.001). Last, but not the least, the evidence suggests a significant recovery of radiotherapy-induced tissue damage (p  =  0.003) and function (p  =  0.012). On average, 1.4 procedures were required to achieve the desired result. Minor complications occurred in 4.8% of the procedures.

CONCLUSIONS

AFT is a promising treatment for fibrosis and scar-related conditions. Future research should focus on determining the long-term effects of AFT on fibrosis, pain and function. In addition, it would be crucial to quantify the mechanical and regenerative properties of fat as well as the effect of added supplements or stem cells.

Salvaging the infected breast implant: results of a retrospective series of 80 consecutive cases

BACKGROUND

Breast implants are widely used in reconstruction after breast cancer. Infection after implant reconstruction is a major complication, with rates ranging from 5 to 30%. This rate is less for pure cosmetic augmentation. Historically, infection of an implant mandated implant removal for sepsis control. An alternative is to attempt to salvage the infected implant. This path can be a long one, requiring surgery for washouts and prolonged antibiotic therapy. This article documents our experience of infected implant salvage over the last 13 years.

METHODS

We conducted a retrospective analysis of all patients who developed a breast implant infection between January 2005 and January 2018. All patients had both clinical signs of infection and a positive bacteriological sample. Patients were divided into two groups: upfront medical therapy (including those requiring secondary surgical salvage) and primary surgery. The salvage procedure was defined as successful when the implant was still in place three months after the initial reconstruction.

RESULTS

Eighty patients were included: 77 in the medical group and 3 in the surgical group. Overall, implant salvage was achieved in 88.8% of women (n=71). Of these, 73.8% (n=59) underwent medical treatment alone and 15% (n=12) underwent medical treatment followed by surgical management. The main causative organism was staphylococcus in 81.2%. When the infection was caused by a coagulase-negative staphylococcus, the rate of success was 98% (p<0.003).

CONCLUSIONS

This case series reports that salvage of an infected breast implant was achievable in up to 90% of women presenting with a documented infection, the majority requiring antibiotic management only. Early intervention is central to success.

Successful Immediate Staged Breast Reconstruction with Intermediary Autologous Lipotransfer in Irradiated Patients

As indications for radiotherapy in mastectomized patients grow, the need for greater reconstructive options is critical. Preliminary research suggests an ameliorating impact of lipotransfer on irradiated patients with expander-to-implant reconstruction. Herein, we present our technique using lipotransfer during the expansion stage to facilitate implant placement.

Long-term impact of lipofilling in hybrid breast reconstruction: retrospective analysis of two cohorts

Lipofilling has recently gained popularity as a tool in primary treatment of breast cancer, and its association with two-stage implant breast reconstruction is considered as standard treatment in many centers. However, no data are available about the long-term results of the association of lipofilling in combination with expander-implant reconstruction. A retrospective analysis was conducted on patients treated between January 2010 and December 2014. Two groups were compared. Group 1 had a standard expander-implant two-stage reconstruction. Group 2 underwent hybrid breast reconstruction (HBR). Patient characteristics, hospitalization, outcomes, reoperation details, outpatient visits, and evaluation questionnaires were taken into consideration. Intergroup comparison was performed using Wilcoxon Mann-Whitney U test and Pearson’s chi-square test or Fisher’s exact test for categorical variables. Two hundred fourteen patients were evaluated: 130 patients in group 1 and 84 patients in group 2. Group 2 showed significant benefits over group 1 in terms of capsular contracture rate, breast pain, and displacement/rotation of the implant (p = 0.005). The HBR protocol is associated with lower rate of capsular contracture, less breast pain at long follow-up times, and lower overall rates of revision surgery compared to standard expander-implant reconstruction. A specific cost analysis will help further clarify the advantages of this protocol over a standard procedure.

Level of Evidence: Level III, risk/prognostic, therapeutic study.

Long-term Follow-up of Autologous Fat Transfer vs Conventional Breast Reconstruction and Association With Cancer Relapse in Patients With Breast Cancer

Importance

Autologous fat transfer (AFT or fat grafting) has become an invaluable tool for the correction of disfiguring deformities after breast cancer surgery. However, clinical and animal studies have shown conflicting results regarding its oncologic safety.

Objective

To determine whether exposure to AFT vs conventional breast reconstruction is associated with increased rates of cancer relapse in patients with breast cancer.

Design, Setting, and Participants

This matched cohort study involved retrospective medical record review to identify all patients in a local patient database receiving AFT between 2006 and 2014. Each AFT case was matched with a nonexposed control patient with similar baseline characteristics. The mean (SD) follow-up of patients receiving AFT was 9.3 (4.9) years including 5.0 (1.7) years following AFT. Control patients were followed up for a mean (SD) of 8.6 (1.8) years from the primary surgery. Patients were identified through the local patient database of the Tergooi Hospital in Hilversum, the Netherlands. A total of 287 patients with breast cancer (300 affected breasts) who received AFT for breast reconstruction after cancer were included in the intervention group. Each AFT case was matched with a respective control patient based on age, type of oncologic surgery, tumor invasiveness, and disease stage. In addition, individual AFT-control pairs were selected to have the same locoregional recurrence-free interval at baseline. Data were analyzed between 2016 and 2017.

Exposures

Reconstruction with AFT vs conventional breast reconstruction or none.

Main Outcomes and Measures

Primary end points were the cumulative incidences of oncologic events in AFT and control patients and their respective hazard ratios.

Results

Of the 587 total patients, all were women and the mean age was 48.1 years for the patients undergoing AFT and 49.4 years for the control patients. Eight locoregional recurrences were observed in the treatment group (287 patients) and 11 among the control group (300 patients), leading to an unadjusted hazard ratio of 0.63 (95% CI, 0.25-1.60; P = .33). No increased locoregional recurrence rates were seen in relevant subgroups based on the type of oncological surgery, tumor invasiveness, or pathological stage. In addition, no increased risks with AFT were detected with respect to distant recurrences or breast cancer-specific mortality.

Conclusions and Relevance

No significant differences in the locoregional recurrence rates between the AFT and control groups were observed after 5 years of follow-up. These findings confirm the results of previous studies; therefore, clinical evidence suggesting that AFT is associated with increased risk for cancer relapse is still lacking.

Better clinical outcome for autologous fat transplant combined with silicone gel prosthesis for breast augmentation: Evidence from meta-analysis

OBJECTIVE

To evaluate the combination of autologous fat transplantation and silicone gel prosthesis implantation for breast augmentation surgery.

METHODS

With "autologous fat", "silicone prosthesis", "combined with", "combination", "breast augmentation" and "clinical effect" as search keywords, a thorough literature search was performed throughout the Chinese databases (CBMdisc, Wanfang, CNKI and Chongqing VIP) and English databases (PUBMED and EMBASE) and after cross-referencing and reading, literature conforming with the inclusion and exclusion criteria were analyzed and significant data related to autologous fat transplantation combined with silicone prosthesis in breast augmentation surgery was collected and meta-analyzed.

RESULTS

21 full-text articles were included into the meta-analysis study: Autologous fat transplantation combined with silicone gel prosthesis implantation not only enhancedthe long-term postoperative breast shape recovery, but also fundamentally managed the underlying drawbacks of using autologous fat graft transplantation or prosthesis alone, decreasing the rate of procedure related morbidity and complications.

CONCLUSION

The application of the combination of autologous fat transplantation with silicone gel prosthesis implantation in breast augmentation surgery has shown good and stable clinical outcome while simultaneously reducing the rate of complication related to the application of either method alone. Hence, this combination is worth exploration and promotion since it offers better manageable clinical outcome at low risk of complication.

Breast Implants and Radiation

One of the most influential factors in the success of breast reconstruction is whether or not radiation therapy has or will be performed. While traditional teaching is that all breasts treated with radiation therapy must be reconstructed with an autologous component, many reconstructive surgeons perform implant-based breast reconstruction without an autologous component and have success doing so. The purpose of this article is to explore the risks, benefits, and nuances of performing implant-based breast reconstruction in the setting of radiation therapy. The authors performed a review of the literature of all topics relevant to performing implant-based reconstruction with radiation therapy.

Radiation-Induced Skin Fibrosis: Pathogenesis, Current Treatment Options, and Emerging Therapeutics

Radiotherapy (RT) has become an indispensable part of oncologic treatment protocols for a range of malignancies. However, a serious adverse effect of RT is radiodermatitis; almost 95% of patients develop moderate to severe skin reactions following radiation treatment. In the acute setting, these can be erythema, desquamation, ulceration, and pain. Chronically, soft tissue atrophy, alopecia, and stiffness can be noted. Radiodermatitis can delay oncologic treatment protocols and significantly impair quality of life. There is currently a paucity of effective treatment options and prevention strategies for radiodermatitis. Importantly, recent preclinical and clinical studies have suggested that fat grafting may be of therapeutic benefit, reversing detrimental changes to soft tissue following RT. This review outlines the damaging effects of RT on the skin and soft tissue as well as discusses available treatment options for radiodermatitis. Emerging strategies to mitigate detrimental, chronic radiation-induced changes are also presented.

Immediate and Long-term Complications of Direct-to-implant Breast Reconstruction after Nipple- or Skin-sparing Mastectomy

Background:

Traditionally, breast reconstruction options after mastectomy comprise an autologous flap or staged expander/implant reconstruction, or a combination of both. Recent introduction of skin or nipple-sparing mastectomies have led to much interest in direct-to-implant immediate breast reconstructions. We performed a retrospective review of our initial experience.

Methods:

Between June 1998 and December 2010, 31 of 671 patients (4.6%) who received implant-only breast reconstruction underwent direct-to-implant immediate breast reconstruction after mastectomy for primary or recurrent cancers, or risk reduction. Their files were audited, and the primary factor examined was the failure of reconstruction with loss of prosthesis. Other complications, revision surgery, and aesthetic result are also recorded.

Results:

The mean follow-up period for the 31 patients was 49.5 months. A total of 45 mastectomies were performed for 21 primary and 4 recurrent breast cancers after previous conservation surgery and radiotherapy (RT), and 20 for risk reduction. Ten patients received RT (4 before mastectomy and 6 afterward). Average size of implants was 380.0 g (range, 205–620 g). The most common postoperative complications were seromas (20%); only 1 implant was lost (2.22%). Nineteen breasts required revision surgery after 6 months with 1 more implant lost. Despite the high revision rate, 28 (90.3%) had excellent or good aesthetic result.

Conclusions:

Immediate single-stage direct-to-implant breast reconstruction has a high rate of both immediate postoperative complications and revisions after 6 months, especially after RT. However, most complications are manageable and do not necessarily result in implant loss. Most cases can have a successful outcome without implant loss with excellent or good cosmetic results.

Fat Chance: The Rejuvenation of Irradiated Skin

Radiotherapy (RT) helps cure and palliate thousands of patients with a range of malignant diseases. A major drawback, however, is the collateral damage done to tissues surrounding the tumor in the radiation field. The skin and subcutaneous tissue are among the most severely affected regions. Immediately following RT, the skin may be inflamed, hyperemic, and can form ulcers. With time, the dermis becomes progressively indurated. These acute and chronic changes cause substantial patient morbidity, yet there are few effective treatment modalities able to reduce radiodermatitis. Fat grafting is increasingly recognized as a tool able to reverse the fibrotic skin changes and rejuvenate the irradiated skin. This review outlines the current progress toward describing and understanding the cellular and molecular effects of fat grafting in irradiated skin. Identification of the key factors involved in the pathophysiology of fibrosis following RT will inform therapeutic interventions to enhance its beneficial effects.

Improved patient-reported outcomes after autologous fat transplantation and corrective surgery after breast surgery

BACKGROUND

Autologous fat transplantation (AFT) is being increasingly used to improve the results after breast-conserving surgery and breast reconstruction. However, studies on patient-reported outcomes (PROs) and health-related quality of life (HRQoL) after AFT are scarce. The aim of this prospective longitudinal case-series study was to assess PRO in women who had undergone AFT after surgery for breast cancer or risk-reducing mastectomy.

METHODS

Fifty women, who had undergone breast-conserving surgery or breast reconstruction, needing corrective surgery, were consecutively included between 2008 and 2013. A 20-item study-specific questionnaire (SSQ) and the Short Form Health Survey (SF-36) were used pre-operatively and 6 months, 1 year and 2 years post-operatively, to evaluate PRO and HRQoL.

RESULTS

The patients underwent three (1-4) AFT procedures, with the injection of 164 ml (median) (range 40-516) fat. Thirty-eight and 34 patients completed the study-specific questionnaire and the SF-36, respectively, both pre-operatively and after 2 years. Sixteen of the 20 items in the SSQ were improved after 2 years, including breast size (p < 0.0001), shape (p < 0.0001), appearance (p < 0.0001), softness of the breast (p = 0.001), pain in the region (p = 0.005), scarring from previous breast surgery (p < 0.001) and willingness to participate in public physical activities (p < 0.001). HRQoL did not largely differ before and after AFT, or between the study group and a reference population.

CONCLUSIONS

AFT alone or in combination with other corrective surgical procedures, improved PRO after breast-conserving surgery and breast reconstruction in both irradiated and non-irradiated women.

The Role of Lipofilling After Breast Reconstruction: Evaluation of Outcomes and Patient Satisfaction with BREAST-Q

INTRODUCTION

The aim of this study was to measure patient satisfaction using the BREAST-Q reconstruction module in patients selected for lipofilling procedures after implant breast reconstructions.

MATERIALS AND METHODS

Seventy patients who underwent breast reconstruction with or without delayed lipofilling were enrolled between 2011 and 2015, and they completed BREAST-Q surveys. We administered the questionnaire electronically 6 months and 1 year after surgery. We divided patients into two groups. In group A, we included patients (46) who underwent secondary lipofilling almost 1 year after implant-based breast reconstruction; in group B (24), patients who underwent implant-based breast reconstruction without any lipofilling procedure. Statistical analysis was performed using descriptive and summary statistics to identify a central tendency between the two groups.

RESULTS

All patients answered the postoperative BREAST-Q reconstruction module. The mean age of the patients was 41 years. Eleven of the 70 patients underwent a bilateral mastectomy. The mean follow-up was 2.5 years. The average amount of fat graft injected was 110 cc. In group A, there were two patients who had a complication: 1 infection and 1 intraoperative implant rupture. The average number of lipofilling procedures was 2.2. After further analysis of the questionnaire, we observed that patients in group A obtained significantly better postoperative results than patients from group B (control) regarding the following items: the ability to wear more fitted clothing; the reconstructed breast softness; symmetry (breasts of equal size relative to the other); reconstructed breast look and touch; amount of implant rippling perceived by the patients; and psychosocial well-being and physical well-being: chest and upper body.

CONCLUSIONS

Our results are encouraging regarding the use of autologous fat grafting to improve cosmetic outcomes and to reduce postoperative pain after breast reconstruction. This is the first study that applied BREAST-Q to breast lipofilling to demonstrate better outcomes achieved by patients who underwent secondary lipostructures.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Two-Stage Prosthetic Breast Reconstruction after Mastectomy with or without Prior Postmastectomy Radiotherapy

BACKGROUND

Two-stage prosthetic breast reconstruction with initial insertion of a tissue expander followed by an implant after a period of inflation is a well-established breast reconstruction option. Most of the current literature concentrates on the immediate setting, and there are only a few reports into delayed cases, especially after postmastectomy radiotherapy (RT). We performed a retrospective review of our experience over a 12.5-year period.

METHODS

Between June 1998 and December 2010, a total of 671 patients received prosthetic-only breast reconstruction. Of these, 170 (25.3%) underwent delayed 2-stage prosthetic breast reconstruction after mastectomy for cancer. Patients were divided into group A, no postmastectomy RT (n = 150), and group B, postmastectomy RT (n = 20). The primary factor examined was the failure of the reconstruction from loss of prosthesis with or without smoking. Other complications, as well as rates of revisional surgery were also recorded.

RESULTS

Expander or implant loss occurred in 3 of 150 patients in group A (2.0%) and 3 of 20 patients in group B (15%; P = 0.02). For nonsmokers, implant loss was 1.6% and 5.6%, respectively (P = NS). Smoking was associated with 1 of the 3 losses in group A and 2 of the 3 in group B (smokers, n = 2; P < 0.01). There was no significant difference in other complications such as seromas or minor wound infections.

CONCLUSIONS

Delayed 2-stage prosthetic breast reconstruction has a low failure rate. It can also be successfully completed in selected patients after postmastectomy RT, but care must be taken with patients who smoke.

Lipofilling effects after breast cancer surgery in post-radiation patients: an analysis of results and algorithm proposal

BACKGROUND

Lipofilling or autologous fat transfer is an established technique in plastic surgery. Herein, we describe the lipofilling effects after implant-based breast reconstruction in post-radiation patients and propose an algorithm for indication of lipofilling.

METHODS

Forty patients with a history of breast cancer were included in this retrospective analysis. Patients had undergone either breast conserving therapy or mastectomy. Twenty-six patients underwent additional radiation therapy. Patients were assessed using a post-radiation skin scoring classification.

RESULTS

In total, 68 lipofilling procedures were analyzed. Scar release, skin softening, improved quality of life, and improvement of post-radiation findings are results of lipofilling with a closed filtration system. In all patients with post-surgical radiation, an improvement of tissue quality was observed. Staging revealed that lipofilling improved mean post-radiation skin scores of 2.40 ± 0.89 to 1.21 ± 0.76 (p ≤ 0.000). There was no recurrence of breast cancer in our study patients.

CONCLUSIONS

This study introduces an algorithm using lipofilling in reconstructive breast surgery and especially in post-radiation patients with low risks as well as very high acceptance in patients with various indications for this procedure. A regenerative aspect was also detectable in patients following radiation therapy and reconstruction. Lipofilling is a safe and effective procedure with a low incidence of minor complications. It is therefore a feasible method to resolve volume deficiencies and asymmetric results after oncologic breast surgery. Nevertheless, a prospective study has now been initiated focusing on the oncologic safety of lipofilling including ultrasound and radiological examinations to validate the findings of this initial study. Level of Evidence: Level IV, therapeutic study.

Use of human fat grafting in the prevention of perineural adherence: Experimental study in athymic mouse

Perineural adherences represent a problem after surgery involving peripheral neural system. Fat-grafting with adipose derived stem cells (ASCs) with their pro-regenerative characteristics can be important to prevent the neural damage or to facilitate the neural regeneration. Our idea was to use the fat-grafting as an anti-adherence device and test its efficacy on a postsurgical scar animal model and comparing to an antiadhesive gel. 32 athymic mice were operated under magnification, we exposed both sciatic nerves. We randomly divided all sciatic nerves into four experimental groups: burning (1), burning + carboxy-methylcellulose and poly- ethylene oxide (CMC-PEO) (2) + human adipose fat tissue (3), control group (4). Bio-mechanical evaluation was performed to measure the peak force required to pull out the nerve from the muscular bed. Results: in the CMC-PEO group the peak pull out force was 0.37 Newton. In the fat grafted group we registered a peak pull out force of 0.35 N (t Student 0.913). In burning group the force necessary to tear the nerve apart was markedly superior (0.46 N). In control group, we reported the minimal strength (0.31 N) to slide the nerve from the tissue. Histologically, in the group treated with fat-grating, a thinner scar layer was highlighted. Considering the results of this study we can support the efficacy in animal experimental model of fat graft as an anti-adherence device in peripheral nerve surgery.

Systematic review of patient factors affecting adipose stem cell viability and function: implications for regenerative therapy

BACKGROUND

The applications for fat grafting have increased recently, within both regenerative and reconstructive surgery. Although fat harvesting, processing and injection techniques have been extensively studied and standardised, this has not had a big impact on the variability of outcome following fat grafting. This suggests a possible larger role of patient characteristics on adipocyte and adipose-derived stem cell (ADSC) viability and function. This systematic review aims to collate current evidence on the effect of patient factors on adipocyte and ADSC behaviour.

METHODS

A systematic literature review was performed using MEDLINE, Cochrane Library and EMBASE. It includes outcomes observed in in vitro analyses, in vivo animal studies and clinical studies. Data from basic science work have been included in the discussion to enhance our understanding of the mechanism behind ADSC behaviour.

RESULTS

A total of 41 papers were included in this review. Accumulating evidence indicates decreased proliferation and differentiation potential of ADSCs with increasing age, body mass index, diabetes mellitus and exposure to radiotherapy and Tamoxifen, although this was not uniformly seen across all studies. Gender, donor site preference, HIV status and chemotherapy did not show a significant influence on fat retention. Circulating oestrogen levels have been shown to support both adipocyte function and graft viability. Evidence so far suggests no significant impact of total cholesterol, hypertension, renal disease, physical exercise and peripheral vascular disease on ADSC yield.

CONCLUSIONS

A more uniform comparison of all factors highlighted in this review, with the application of a combination of tests for each outcome measure, is essential to fully understand factors that affect adipocyte and ADSC viability, as well as functionality. As these patient factors interact, future studies looking at adipocyte viability need to take them into consideration for conclusions to be meaningful. This would provide crucial information for surgeons when deciding appropriate volumes of lipoaspirate to inject, improve patient selection, and counsel patient expectations with regards to outcomes and likelihood for repeat procedures. An improved understanding will also assist in identification of patient groups that would benefit from graft enrichment and cryopreservation techniques.