Determining the oncological risk of autologous lipoaspirate grafting for post-mastectomy breast reconstruction

Oncological Safety of Autologous Fat Grafting for Breast Reconstruction

BACKGROUND

Autologous fat grafting has become a vital component of breast reconstruction. However, concerns remain regarding the safety of fat grafting after oncological resection and breast reconstruction. The purpose of the study was to evaluate the association of fat grafting after breast reconstruction with metastasis and death in breast cancer patients.

METHODS

A retrospective, population-based cohort study was conducted using deidentified claims data from 2001 to 2018 and included privately insured patients with breast cancer who underwent breast reconstruction after surgical resection. Breast reconstruction patients who underwent fat grafting were compared with those not undergoing fat grafting, evaluating metastasis and death up to 15 years after reconstruction. One-to-one propensity score matching was used to account for selection bias on patient risk factors comparing those with and without fat grafting.

RESULTS

A total of 4709 patients were identified who underwent breast reconstruction after lumpectomy or mastectomy, of which 368 subsequently underwent fat grafting. In the propensity score-matched patients, fat grafting was not associated with an increased risk of lymph node metastasis (9.7% fat-grafted vs 11.4% in non-fat-grafted, P = 0.47) or distant metastasis (9.1% fat-grafted vs 10.5% in non-fat-grafted, P = 0.53). There was no increased risk of all-cause mortality after fat grafting for breast reconstruction (3.9% fat-grafted vs 6.6% non-fat-grafted, P = 0.10).

CONCLUSIONS

Among breast cancer patients who subsequently underwent fat grafting, compared with no fat grafting, no significant increase was observed in distant metastasis or all-cause mortality. These findings suggest that autologous fat grafting after oncologic resection and reconstruction was not associated with an increased risk of future metastasis or death.

Oncologic Safety in Autologous Fat Grafting After Breast Conservation Therapy: A Systematic Review and Meta-analysis of the Literature

BACKGROUND

Autologous fat grafting (AFG) is often used to reconstruct defects after breast conservation therapy (BCT). However, concerns exist about the possibility of AFG-related recurrence or metastasis. This study aims to evaluate the literature to evaluate oncologic outcomes in patients undergoing AFG at the time of BCT.

METHODS

A systematic review of articles related to AFG based reconstruction at the time of BCT from 1970 to 2021 was performed via PubMed. Patients were grouped based on the presence or lack of AFG usage at the time of BCT, and oncologic outcomes and complications were compared.

RESULTS

Of the 146 articles identified, 15 were included. Nine hundred patients underwent BCT alone and 1063 patients underwent BCT with AFG patients. Similar average follow-up time was observed between the groups, 58.7 months (BCT only) and 55.2 months (BCT with AFG). On pooled analysis, no difference was identified in local recurrence 4.8% (43 patients) of the BCT group and 3% (32 patients) in the AFG group (P = 0.8), metastasis 4.8% (43 patients) of the BCT group and 6.9% (73 patients) in the AFG group (P = 0.3), or fat necrosis (P = 0.44). Meta-analysis additionally did not identify any statistically significant odds ratios between the BCT only group and BCT with AFG group when evaluated for total recurrence, local recurrence, metastasis or fat necrosis.

CONCLUSIONS

The results show no significant difference in cancer recurrence or metastasis in the BCT only group versus BCT and AFG, showing that fat grafting has safe outcomes.

SINGLE-CENTER ONCOLOGIC OUTCOME OF FAT TRANSFER FOR BREAST RECONSTRUCTION FOLLOWING MASTECTOMY IN 1000 CANCER CASES - A MATCHED CASE-CONTROL STUDY

BACKGROUND

Autologous fat transfer (AFT) has an important role in breast reconstructive surgery. Nevertheless, Some concerns remain with regards to its oncological safety. We present a single center case-matching study analysing the impact of AFT in cumulative incidence of local recurrences (LR).

MATERIALS AND METHODS

From a prospectively maintained database, we identified 902 patients who underwent 1025 breast reconstructions from 2005 to 2017. Data regarding demographics, tumor characteristics, surgery details and follow-up were collected. Exclusion criteria were patients with distant metastases at diagnosis, recurrent tumor or incomplete data regarding primary tumor, patients who underwent prophylactic mastectomies and breast-conserving surgeries. Statistical analysis was done to evaluate the impact of the variables on the incidence of LR. A p-value < 0.05 was considered statistically significant.

RESULTS

After 1:n case-matching, we selected 919 breasts, out of which 425 (46.2%) patients received at least one AFT session vs 494 (53.8%) control cases. LR had an overall rate of 6.8% and we found LR in 14 (3.0%) AFT cases and 54 (9.6%) controls. Statistical analysis showed that AFT did not increase risk of LR: HR 0.337 (CI 0.173-0.658), p=0.00007. Multivariate analysis identified IDC subtype and lymph node metastases to have an increased risk of local recurrences (HR > 1). Conversely, positive hormonal receptor status was associated with a reduced risk of events (HR < 1).

CONCLUSIONS

AFT was not associated with a higher probability of locoregional recurrence in patients undergoing breast reconstruction therefore it can be safely used for total breast reconstruction or aesthetic refinements.LEVEL OF EVIDENCE: 3.

Oncologic safety of breast reconstruction with autologous fat grafting: A systematic review and meta-analysis

BACKGROUND

Autologous fat grating has become increasingly popular as a breast reconstructive procedure. Nevertheless, preclinical studies show that fat transfer to a previous breast cancer site could activate latent cancer cells, creating a favourable environment for disease recurrence. A systematic review and meta-analysis was performed to investigate whether fat grafting increases the risk of locoregional recurrence in patients formerly treated for breast cancer.

METHODS

Based on PRISMA guidelines, a systematic review searching for randomised clinical trials and matched cohorts on the topic was performed in the electronic databases Pubmed, Embase, Web of Science, and Cochrane. The date of the last search was July 20, 2021. The meta-analysis assessed the comparison of locoregional recurrence between groups.

RESULTS

From a total of 558 publications, data from nine matched cohorts (1.6%) reporting on 4247 subjects (1590 and 2657 subjects, respectively, in lipofilling and control groups) were suitable for inclusion in the meta-analysis. Neither of the outcomes had a statistically significant difference for disease recurrence. For the primary outcome, comparing locoregional recurrence rates between groups, the incidence rate ratio was 0.92 (95% CI: 0.68-1.26; P = 0.620).

CONCLUSION

The present meta-analysis, which comprises the outcomes of the individual studies with the best current evidence on the topic so far, strengthens the evidence favouring the oncologic safety of lipofilling for breast reconstruction.

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction after Mastectomy for cancer: A case-control study

OBJECTIVE

The use of autologous fat grafting in the context of breast reconstruction is still a matter of controversy. The objective of this study was to compare the local relapse rate in women who had a fat grafting session in the context of breast reconstruction after breast cancer management, to those who had breast reconstruction without fat grafting.

METHODS

We performed a retrospective, monocentric, case-control study from January 2007 to December 2017 in our hospital. The cases included women who underwent breast reconstruction with autologous fat grafting and controls, undergoing breast reconstruction without fat grafting. We compared survival and local recurrence between the two groups.

RESULTS

412 women were included: 109 (26.5%) in the lipofilling group and 303 women (73.5%) in the "no lipofilling" group. In the overall study population, lipofilling did not appear to be a predictive factor for recurrence, HR = 1.39 [0.63 - 3.06], p = 0.41; or a predictive factor for overall survival, HR = 0.84 [0.23 - 3.02], p = 0.79, or for distant metastases, HR = 1.10 [0.43 - 2.79], p = 0.84. In contrast, in the subgroup of women treated for invasive cancer, the multivariate analysis showed that lipofilling in this context was an independent predictive factor for local recurrence (HR= 5.06 [1.97 - 10.6], p = 0.04).

CONCLUSION

we found an increased risk of local recurrence after lipofilling in women who were managed for invasive breast cancer. This suggests that special consideration should be given to women who have had invasive breast cancer before lipofilling.

Update on the Basic Science Concepts and Applications of Adipose-Derived Stem Cells in Hand and Craniofacial Surgery

SUMMARY

Adipose-derived stem cell therapy offers plastic surgeons a novel treatment alternative for conditions with few therapeutic options. Adipose-derived stem cells are a promising treatment because of their broad differentiation potential, capacity for self-renewal, and ease of isolation. Over the past decade, plastic surgeons have attempted to harness adipose-derived stem cells' unique cellular characteristics to improve the survival of traditional fat grafting procedures, a process known as cell-assisted lipotransfer. However, the full implications of cell-assisted lipotransfer in clinical practice remain incompletely understood, stressing the urgent need to assess the scientific evidence supporting adipose-derived stem cell-based interventions. Furthermore, with the strict regulatory climate surrounding tissue explantation therapies, reviewing the safety and efficacy of these treatments will clarify their regulatory viability moving forward. In this report, the authors provide a comprehensive, up-to-date appraisal of best evidence-based practices supporting adipose-derived stem cell-derived therapies, highlighting the known mechanisms behind current clinical applications in tissue engineering and regenerative medicine specific to plastic and reconstructive surgery. The authors outline best practices for the harvest and isolation of adipose-derived stem cells and discuss why procedure standardization will elucidate the scientific bases for their broad use. Finally, the authors discuss challenges posed by U.S. Food and Drug Administration oversight of these cell-based therapies and examine the role of adipose-derived stem cell-based applications in the future of plastic surgery.

Autologous Fat Grafting Does Not Increase Risk of Oncologic Recurrence in the Reconstructed Breast

INTRODUCTION

Autologous fat grafting (AFG) is a popular and effective method of breast reconstruction after mastectomy; however, the oncological safety of AFG remains in question. The aim of this study was to determine whether AFG increases the risk of cancer recurrence in the reconstructed breast.

METHODS

A matched, case-control study was conducted from 2000 to 2017 at the senior author's institution. Inclusion was limited to female patients who underwent mastectomy and breast reconstruction with or without AFG. Data were further subdivided at the breast level. χ analyses were used to test the association between AFG status and oncologic recurrence. A Cox proportional-hazards model was constructed to assess for possible differences in time to oncologic recurrence. The probability of recurrence was determined by Kaplan-Meier analyses and confirmed with log-rank testing.

RESULTS

Overall, 428 breasts met study criteria. Of those, 116 breasts (27.1%) received AFG, whereas 312 (72.9%) did not. No differences in the rates of oncologic recurrence were found between the groups (8.2% vs 9.0%, P < 1.000). Unadjusted (hazard ratio = 1.03, confidence interval = 0.41-2.60, P < 0.957) and adjusted hazard models showed no statistically significant increase in time to oncologic recurrence when comparing AFG to non-AFG. In addition, no statistical differences in disease-free survival were found (P = 0.96 by log rank test).

CONCLUSION

Autologous fat grafting for breast reconstruction is oncologically safe and does not increase the likelihood of oncologic recurrence. Larger studies (eg, meta analyses) with longer follow-up are needed to further elucidate the long-term safety of AFG as a reconstructive adjunct.

Analysis of oncological safety of autologous fat grafting after immediate breast reconstruction

Background

Fat grafting is now a common procedure for breast reconstruction. Many clinical studies have reported its aesthetic efficacy and oncological safety, but some experimental studies raise about the recurrence risk because of its regenerating property. This study aims to investigate the possibility of cancer recurrence associated with fat grafting.

Methods

In this retrospective cohort study, we analyzed a total of 339 patients who had undergone immediate reconstructive surgery after nipple-sparing mastectomy (NSM) or skin-sparing mastectomy (SSM) in our institution between February 28, 2009 and March 23, 2019. Patients who had undergone breast conserving surgery, radical mastectomy, or delayed reconstruction were excluded. We used univariate and multivariate Cox proportional hazards regression models to evaluate the association between fat grafting and cancer recurrence.

Results

Among the 339 patients during a median follow-up of 52 months, 27 patients (8.0%) were confirmed to have recurrent cancer. Of 67 patients who had undergone fat grafting, 10 patients were confirmed to have cancer recurrence. In multivariate analyses, fat grafting [hazard ratio (HR), 2.52; 95% CI, 1.005-6.317; P=0.0488] was independently associated with cancer recurrence.

Conclusions

In population of breast cancer patient who underwent immediate reconstruction in our institution, fat grafting showed significant higher risk of cancer recurrence. Although these results are at odds with many existing studies, it suggests that more careful follow-up may be necessary for patients who had undergone fat grafting after reconstructive surgery.

Autologous fat grafting in breast reconstruction: implications for follow-up and surveillance

The procedural volume of autologous fat grafting (AFG) has risen over the past several years, specifically in the setting of breast reconstruction, despite controversy surrounding its oncologic safety. While some in vitro and animal models have cast doubt on the oncologic safety of AFG, there is no clinical evidence that AFG in breast reconstruction is associated with an increased risk of cancer development or recurrence or an inability to adequately assess changes in the breast. That being said, recommendations regarding surveillance and follow-up after AFG in breast reconstruction are largely surgeon directed and differ across practices. The purpose of this review is to summarize the current literature and provide evidence-based recommendations.

Oncologic Safety and Surveillance of Autologous Fat Grafting following Breast Conservation Therapy

BACKGROUND

Autologous fat grafting is a useful adjunct following breast reconstruction. The impact of autologous fat grafting on oncologic safety and surveillance remains questionable, particularly following breast conservation therapy.

METHODS

The authors performed a retrospective review of patients who underwent delayed fat grafting following breast conservation therapy between 2006 and 2016. A control group of conservatively managed patients without grafting was matched for cancer stage, age, body mass index, and follow-up. Outcomes included locoregional recurrence and oncologic surveillance.

RESULTS

Seventy-two patients were identified per cohort. There were no differences in median age (50 years versus 51 years; p = 0.87), body mass index (28.2 kg/m versus 27.2 kg/m; p = 0.38), or length of follow-up (61.9 months versus 66.8 months; p = 0.144) between controls and grafted patients, respectively. Overall, four patients in each cohort experienced recurrence (5.6 percent; p = 1.00) with similar cumulative incidence estimates observed (log-rank test, p = 0.534). There were no significant differences in palpable mass (9.7 percent versus 19.4 percent; p = 0.1), fat necrosis (34.7 percent versus 33.3 percent; p = 0.86), calcifications (37.5 percent versus 34.7 percent; p = 0.73), or indication for breast biopsy (15.3 percent versus 22.2 percent; p = 0.23) between breast conservation and breast conservation therapy plus autologous fat grafting cohorts, respectively.

CONCLUSIONS

Overall, the authors found no difference in recurrence rates after breast conservation with or without delayed fat grafting. Furthermore, there were no differences in the rates of fat necrosis, palpable mass, and abnormal radiographic findings. This study represents the longest follow-up to date in in a large matched study of autologous fat grafting with breast conservation therapy demonstrating oncologic safety and no interference with follow-up surveillance.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Fat Therapeutics: The Clinical Capacity of Adipose-Derived Stem Cells and Exosomes for Human Disease and Tissue Regeneration

Fat grafting is a well-established surgical technique used in plastic surgery to restore deficient tissue, and more recently, for its putative regenerative properties. Despite more frequent use of fat grafting, however, a scientific understanding of the mechanisms underlying either survival or remedial benefits of grafted fat remain lacking. Clinical use of fat grafts for breast reconstruction in tissues damaged by radiotherapy first provided clues regarding the clinical potential of stem cells to drive tissue regeneration. Healthy fat introduced into irradiated tissues appeared to reverse radiation injury (fibrosis, scarring, contracture and pain) clinically; a phenomenon since validated in several animal studies. In the quest to explain and enhance these therapeutic effects, adipose-derived stem cells (ADSCs) were suggested as playing a key role and techniques to enrich ADSCs in fat, in turn, followed. Stem cells - the body's rapid response 'road repair crew' - are on standby to combat tissue insults. ADSCs may exert influences either by releasing paracrine-signalling factors alone or as cell-free extracellular vesicles (EVs, exosomes). Alternatively, ADSCs may augment vital immune/inflammatory processes; or themselves differentiate into mature adipose cells to provide the 'building-blocks' for engineered tissue. Regardless, adipose tissue constitutes an ideal source for mesenchymal stem cells for therapeutic application, due to ease of harvest and processing; and a relative abundance of adipose tissue in most patients. Here, we review the clinical applications of fat grafting, ADSC-enhanced fat graft, fat stem cell therapy; and the latest evolution of EVs and nanoparticles in healing, cancer and neurodegenerative and multiorgan disease.

Safety and Regulation of Fat Grafting

Today, fat grafting has wide applicability across plastic surgery disciplines, including both aesthetic and reconstructive procedures. However, much controversy has surrounded adipose tissue transfer throughout the 20th century, necessitating extensive research to improve the fat grafting process and to better understand its associated complications and benefits. Initial concerns included the technical difficulties of properly handling and processing adipose to ensure adequate outcomes. As these issues were addressed, more modern concerns were raised by the U.S Food and Drug Administration and the general scientific community regarding the oncological potential of adipose tissue and its potential interference with breast cancer screenings. Today, many formalized clinical studies have evidenced the safety of fat grafting, allowing the procedure to gain widespread popularity and opening avenues for future applications.

The use of autologous fat grafts in breast surgery: A literature review

Autologous fat injection was first described roughly a century ago and has been used in surgery ever since. In addition to its use in many surgical fields, it is also frequently used for both aesthetic and reconstructive purposes in breast surgery. Since the application of fat grafting in breast surgery has steadily increased, studies investigating its reliability have simultaneously become increasingly common. Previous studies have reported that the use of fat grafting in breast surgery is reliable, but some pending questions remain about its routine use. In order to use fat grafts successfully in breast surgery, it is necessary to be familiar with the structure and content of adipose tissue, the efficacy of adipose stem cell-enriched fat grafts, the oncological safety of fat grafts, and the problems that may occur in the radiological follow-up of patients who undergo fat grafting procedures. In this literature review, we aim to discuss the use of fat grafts in breast surgery by investigating these common problems.

International Expert Panel Consensus on Fat Grafting of the Breast

Background

Autologous fat grafting has broad applications in reconstructive and aesthetic breast surgery as a natural filler and for its regenerative purposes. Despite the widespread use of fat grafting, there remains no shared consensus on what constitutes the optimal fat grafting technique and its oncological safety. For this reason, the authors of this study have organized a Survey and an International Consensus Conference that was held at the Aesthetic Breast Meeting in Milan (December 15, 2018).

Methods

All studies on fat grafting, both for breast aesthetic and reconstructive purposes, were electronically screened. The literature review led to 17 "key questions" that were used for the Survey. The authors prepared a set of 10 "key statements" that have been discussed in a dedicated face-to-face session during the meeting.

Results

The 10 key statements addressed all the most debated topics on fat grafting of the breast. Levels of evidence for the key statements ranged from III to IV with 2 statements (20%) supported by a level of evidence III and 6 statements (60%) by level of evidence IV. Overall consensus was reached for 2 statements (20%) with >75% agreement reached for 7 statements.

Conclusions

The survey demonstrated a diversity of opinion and attitude among the panelists with regard to technique. Clear recommendations for evidence-based clinical practice for fat grafting use both in aesthetic and reconstructive breast surgery could not be defined due to the scarcity of level 1 or 2 studies.

Autologous Fat Grafting for Craniofacial Reconstruction in Oncologic Patients

Due to the anatomical and functional complexity of the region, craniofacial tumor removal requires some of the most challenging surgical approaches, often complemented with advanced chemo-radiotherapy techniques. However, these modern therapies often lead to sequelae that can drastically reduce the quality of life for the surviving patients. Recent advances in the field of regenerative medicine opened new avenues for craniofacial reconstruction following head and neck cancer treatment. One of the most promising recent strategies relies on the use of autologous fat transplant. In this mini review, we briefly present some of the fat’s biological properties that make it an ideal tissue for craniofacial reconstruction following cancer treatment. We then outline the recent advances that led to a better understanding of the detailed anatomy of the craniofacial fat depots. Furthermore, we provide a succinct review of the methods used for fat harvesting, processing and engrafting in the craniofacial area after head and neck tumor removal, discussing their main applications, advantages and limitations.

Evaluation of the in vivo wound healing potential of the lipid fraction from activated platelet-rich plasma

Previous in vitro studies suggest a direct relevance for the peptide-free lipid fraction (LF) of platelet-rich plasma (PRP) in biological mechanisms related to wound healing. However, there are no scientific reports to date on the wound healing activities of this lipid component in vivo. Thus, the present study provides a scientific evaluation for the wound healing potential of the lipid portion of the activated PRP. For the wound healing activity assessment, in vivo full-thickness excisional wounds were created on the dorsal skin of Sprague-Dawley rats. Lipid extract from pooled PRP was applied topically to the wounds on 0, 3, and 7 days after injury. Histological assessment of epidermal and dermal regeneration, granulation tissue thickness and angiogenesis by Sirius red and Masson's trichrome staining, in addition to immunohistochemical staining for transforming growth factor beta-1 (TGF-β1), collagen type I (COL I), and collagen type III (COL III) were performed on skin biopsies at 3, 7 and 14 days. The total histological scores of the LF group were significantly higher than the 25% dimethylsulfoxide-control group. According to the immunohistochemical staining, the observed expression changes for TGF-β1, COL I and III at 3, 7, and 14 days after wounding were significantly better in the study group than the control group. Furthermore, COL I/III ratio in the lipid extract-treated group at day 14 was much higher than that of the control group. Meanwhile, analysis of the data also indicated that the LF has less positive effects on all evaluated parameters than PRP. From the present data, it could be concluded that the peptide-free LF of PRP has potent wound healing capacity in vivo for cutaneous wounds, although not as much as that of PRP. Strengthening our understanding of the wound healing potential of lipid components of PRP and platelet-derived lipid factors may provide new avenues for improving the healing process of a wound with elevated protease activity.

Does lipofilling after oncologic breast surgery increase the amount of suspicious imaging and required biopsies?-A systematic meta-analysis

OBJECTIVE

The aim of our systematic meta-analysis was to find out if lipofilling to the breast alters follow-up imaging procedures and leads to an increased number of biopsies because of suspicious findings.

METHODS

We conducted a systematic meta-analysis of the literature including all prospective and retrospective studies focusing on imaging outcomes in patients with a history of breast cancer who have received one or more lipofilling procedures after oncologic surgery to the breast.

RESULTS

Twelve studies met the inclusion criteria, comprising 1711 patients and at least 2261 lipofilling procedures. 564 patients (33%) were followed up only with ultrasound, 735 patients (43%) only received mammography, 273 (16%) had a combination of ultrasound, mammography and MRI, and 37 patients (2.1%) were followed up via ultrasound and mammography. A collective of 102 patients making up a matched-cohort study received ultrasound, mammography, MRI, and PET/CT, while only 51 of them made up the investigation group who had autologous fat grafting (3%). Biopsy rates were 1%-24% with a medium of 6.5% over all groups. Medium follow-up was 18.8 months (range 6-50 months). The rate of local oncologic events among the patients with lipofilling procedures detected during the study periods was 0.7%.

CONCLUSION

Lipofilling to the breast after oncologic operations appears to be a safe procedure with overall low biopsy and local recurrence rate. Suspicious imaging occurs in most cases out of physiologic remodeling and inflammation processes at the operation site and needs to be distinguished from malignant focusses. The amount of required biopsies stands in relation to the used imaging method and the time to follow-up.

Principles and Applications of Fat Grafting in Plastic Surgery

Autologous fat transplantation has become increasingly popular in recent years. Its biocompatable properties and availability made it a widely used treatment modality for soft tissue augmentation and volume replacement in both reconstructive and aesthetic plastic surgery. Multiple protocols and clinical applications have been described in the literature, with wide variations in the harvesting, processing, and injection techniques. In this review, the authors will discuss the basic principles and clinical applications of fat grafting in plastic and reconstructive surgery. The article will then conclude with a discussion of fat grafting limitations as well as potential future applications, giving the reader a well-rounded understanding of autologous fat transfer.

Adipose-Derived Stem Cells in Cancer Progression: New Perspectives and Opportunities

Growing importance has been attributed to interactions between tumors, the stromal microenvironment and adult mesenchymal stem cells. Adipose-derived stem cells (ASCs) are routinely employed in regenerative medicine and in autologous fat transfer procedures. To date, clinical trials have failed to demonstrate the potential pro-oncogenic role of ASC enrichment. Nevertheless, some pre-clinical studies from in vitro and in vivo models have suggested that ASCs act as a potential tumor promoter for different cancer cell types, and support tumor progression and invasiveness through the activation of several intracellular signals. Interaction with the tumor microenvironment and extracellular matrix remodeling, the exosomal release of pro-oncogenic factors as well as the induction of epithelial-mesenchymal transitions are the most investigated mechanisms. Moreover, ASCs have also demonstrated an elective tumor homing capacity and this tumor-targeting capacity makes them a suitable carrier for anti-cancer drug delivery. New genetic and applied nanotechnologies may help to design promising anti-cancer cell-based approaches through the release of loaded intracellular nanoparticles. These new anti-cancer therapies can more effectively target tumor cells, reaching higher local concentrations even in pharmacological sanctuaries, and thus minimizing systemic adverse drug effects. The potential interplay between ASCs and tumors and potential ASCs-based therapeutic approaches are discussed.

Perspectives for Clinical Translation of Adipose Stromal/Stem Cells

Adipose stromal/stem cells (ASCs) are an ideal cell type for regenerative medicine applications, as they can easily be harvested from adipose tissue in large quantities. ASCs have excellent proliferation, differentiation, and immunoregulatory capacities that have been demonstrated in numerous studies. Great interest and investment have been placed in efforts to exploit the allogeneic use and immunomodulatory and anti-inflammatory effects of ASCs. However, bridging the gap between in vitro and in vivo studies and moving into clinical practice remain a challenge. For the clinical translation of ASCs, several issues must be considered, including how to characterise such a heterogenic cell population and how to ensure their safety and efficacy. This review explores the different phases of in vitro and preclinical ASC characterisation and describes the development of appropriate potency assays. In addition, good manufacturing practice requirements are discussed, and cell-based medicinal products holding marketing authorisation in the European Union are reviewed. Moreover, the current status of clinical trials applying ASCs and the patent landscape in the field of ASC research are presented. Overall, this review highlights the applicability of ASCs for clinical cell therapies and discusses their potential.

Making Sense of Stem Cells and Fat Grafting in Plastic Surgery: The Hype, Evidence, and Evolving U.S. Food and Drug Administration Regulations

Autologous fat grafting and adipose-derived stem cells are two distinct entities with two different risk profiles, and should be regulated as such. Autologous fat grafting prepared with the additional step of stromal vascular fraction isolation is considered a form of "stem cell therapy" given the high concentration of stem cells found in stromal vascular fraction. Much ambiguity existed in the distinction between autologous fat grafting and stromal vascular fraction initially, in terms of both their biological properties and how they should be regulated. The market has capitalized on this in the past decade to sell unproven "stem cell" therapies to unknowing consumers while exploiting the regulatory liberties of traditional fat grafting. This led to a Draft Guidance from the U.S. Food and Drug Administration in 2014 proposing stricter regulations on fat grafting in general, which in turn elicited a response from plastic surgeons, who have safely used autologous fat grafting in the clinical setting for over a century. After a series of discussions, the U.S. Food and Drug Administration released its Final Guidance in November of 2017, which established clear distinctions between autologous fat grafting and stromal vascular fraction and their separate regulations. By educating ourselves on the U.S. Food and Drug Administration's final stance on fat grafting and stem cell therapy, we can learn how to navigate the regulatory waters for the two entities and implement their clinical use in a responsible and informed manner.

Oncologic Safety of Fat Grafting for Autologous Breast Reconstruction in an Animal Model of Residual Breast Cancer

BACKGROUND

Clinical outcomes suggest that postoncologic reconstruction with fat grafting yields cumulative incidence curves of recurrence comparable to those of other breast reconstruction procedures; however, results from experimental research studies suggest that adipose stem cells can stimulate cancer growth. In this study, a novel animal model of residual cancer was developed in mouse mammary pads to test whether lipofilling impacts the probability of locoregional recurrence of breast cancer after breast conserving surgery.

METHODS

Mammary fat pads of female NOD-SCID gamma mice were each injected with MCF-7 cells in Matrigel. Tumors were allowed to engraft for 2 weeks, after which time either sterile saline (n = 20) or human fat graft (n = 20) was injected adjacent to tumor sites. After 8 weeks, tumors were assessed for volume measurement, histologic grade, Ki67 positivity, and metastatic spread.

RESULTS

Animals receiving lipofilling after tumor cell engraftment had lower tumor volume and mass (p = 0.046 and p = 0.038, respectively). Macroscopic invasion was higher in the saline group. Histologic grade was not significantly different in the two groups (p = 0.17). Ki67 proliferation index was lower in tumors surrounded by fat graft (p = 0.01). No metastatic lesion was identified in any animal.

CONCLUSIONS

Adipose transfer for breast reconstruction performed in the setting of residual breast tumor in a clinically relevant animal model did not increase tumor size, proliferation, histologic grade, or metastatic spread. This study supports the oncologic safety of lipofilling as part of the surgical platform for breast reconstruction after cancer therapy.

Breast reconstruction with breast implants

BACKGROUND

Breast cancer is the most common noncutaneous malignancy among women worldwide. After a breast cancer removal procedure, women are asked to decide about breast reconstruction, mainly to improve their life quality, and they can choose from among many options. Broadly, there are two different types of breast reconstruction procedures: prosthetic implant-based reconstruction and autologous tissue-based reconstruction.

METHODS

Implant-breast reconstruction is a minimally invasive procedure compared with autologous breast reconstruction. It is associated with fewer short- and long-term complications.

RESULTS

The ideal candidates for implant-based reconstruction are patients with non-redundant soft tissue coverage, who desire a moderate sized non-ptotic breast and have not been previously irradiated.

CONCLUSION

The state of the art for implant-breast reconstruction is briefly described in this article.

Adipose-derived stem cell-mediated paclitaxel delivery inhibits breast cancer growth

Breast cancer represents the main malignancy in women and autologous fat grafting is a diffuse procedure in the management of post-surgical breast defects causing patients’ psychosocial problems, with high costs for the public health. Recently, beneficial effects of fat grafting during post-surgical breast reconstruction have been amplified from the enrichment with human adipose-derived stem cells (ASCs) present in the stromal vascular fraction (SVF) of adult adipose tissue isolated during intraoperatory procedures. The major concern about the ASC enrichment during post-surgery breast reconstruction depends on their potential ability to release growth factors and hormones that can promote proliferation of residual or quiescent cancer cells, with the risk of de novo cancer development or recurrence. The recent description that adult stem cells primed in vitro may be vehicle for anti-cancer drug delivery offers a new vision concerning the role of ASCs in breast reconstruction after cancer surgery. Paclitaxel (PTX) is a chemotherapeutic agent acting as a microtubule-stabilizing drug inhibiting cancer cell mitotic activity. We optimized PTX loading and release in cultured ASCs and then analyzed the effects of PTX-loaded ASCs and their conditioned medium on CG5 breast cancer survival, proliferation and apoptosis in vitro, and inCG5 xenograft in vivo. We documented that ASCs can uptake and release PTX in vitro, with slight cytotoxic effects. Interestingly, PTX-loaded ASCs in co-culture, as well as conditioned medium alone, inhibited CG5 cell proliferation and survival in vitro and xenograft tumor growth in vivo. The antitumor effect of PTX-loaded ASCs may offer a new perspective concerning the use of ASCs during breast reconstruction becoming an additional local preventive chemotherapeutic agent against tumor recurrence. However, further experiments in vitro and in vivo are needed to collect more evidence confirming the efficacy and safety in cancer patients.

Meta-analysis of the oncological safety of autologous fat transfer after breast cancer

Lipofilling ok

Immediate reconstruction with autologous fat grafting: influence in breast cancerregional recurrence

Objective

to evaluate local and systemic recurrence of breast cancer in patients submitted to autologous fat grafting in the immediate reconstruction after conservative surgery for breast cancer.

Methods

this is a historical cohort study comparing 167 patients submitted to conservative surgery without reconstruction (conservative surgery group) with 27 patients submitted to conservative treatment with immediate graft reconstruction, following the Coleman's technique (lipofilling group). All patients had invasive carcinoma and were operated by a single surgeon from 2004 to 2011. The postoperative follow-up time was 36 months.

Results

the overall incidence of local recurrence was 2.4%. No patient in the lipofilling group had local recurrence during the study period. For systemic recurrence, the rates obtained were 3.7% (one patient) for the fat grafting group and 1.8% (three patients) for the conservative surgery group without reconstruction.

Conclusion

there was no significant difference for local or systemic recurrence in the groups studied. Immediate autologous fat grafting appears to be a safe procedure.

Adipose-Derived Stem Cells in Aesthetic Surgery: A Mixed Methods Evaluation of the Current Clinical Trial, Intellectual Property, and Regulatory Landscape

BACKGROUND

Adipose tissue, which can be readily harvested via a number of liposuction techniques, offers an easily accessible and abundant source of adipose-derived stem cells (ASCs). Consequently, ASCs have become an increasingly popular reconstructive option and a novel means of aesthetic soft tissue augmentation.

OBJECTIVES

This paper examines recent advances in the aesthetic surgery field, extending beyond traditional review formats to incorporate a comprehensive analysis of current clinical trials, adoption status, and the commercialization pathway.

METHODS

Keyword searches were carried out on clinical trial databases to search for trials using ASCs for aesthetic indications. An intellectual property landscape was created using commercial software (Thomson Reuters Thomson Innovation, New York, NY). Analysis of who is claiming what in respect of ASC use in aesthetic surgery for commercial purposes was analyzed by reviewing the patent landscape in relation to these techniques. Key international regulatory guidelines were also summarized.

RESULTS

Completed clinical trials lacked robust controls, employed small sample sizes, and lacked long-term follow-up data. Ongoing clinical trials still do not address such issues. In recent years, claims to intellectual property ownership have increased in the "aesthetic stem cell" domain, reflecting commercial interest in the area. However, significant translational barriers remain including regulatory challenges and ethical considerations.

CONCLUSIONS

Further rigorous randomized controlled trials are required to delineate long-term clinical efficacy and safety. Providers should consider the introduction of patient reported outcome metrics to facilitate clinical adoption. Robust regulatory and ethical policies concerning stem cells and aesthetic surgery should be devised to discourage further growth of "stem cell tourism."

Impact of Platelet-Rich Plasma on Viability and Proliferation in Wound Healing Processes after External Radiation

Platelet-rich plasma is a current subject of studies on chronic wound healing therapy due to possible pro-angiogenic effects. Microvascular compromise represents the major component in radiogenic wound healing complications. The effects of platelet-rich plasma on irradiated cells of the cutaneous wound healing process are poorly understood so far. In this study, the interaction of endothelial cells and adipose-derived stem cells in conjunction with treatment with platelet-rich plasma is investigated in the context of radiation effects. Therefore, the expression of surface-marker CD90 and CD31 was determined. Moreover, cell proliferation and viability after external radiation was analyzed with and without treatment by platelet-rich plasma.

Adipose-Derived Stem Cells in Novel Approaches to Breast Reconstruction: Their Suitability for Tissue Engineering and Oncological Safety

Adipose-derived stem cells (ADSCs) are rapidly becoming the gold standard cell source for tissue engineering strategies and hold great potential for novel breast reconstruction strategies. However, their use in patients with breast cancer is controversial and their oncological safety, particularly in relation to local disease recurrence, has been questioned. In vitro, in vivo, and clinical studies using ADSCs report conflicting data on their suitability for adipose tissue regeneration in patients with cancer. This review aims to provide an overview of the potential role for ADSCs in breast reconstruction and to examine the evidence relating to the oncologic safety of their use in patients with breast cancer.

Modern trends in lipomodeling

Lipomodeling is the process of relocating autologous fat to change the shape, volume, consistency, and profile of tissues, with the aim of reconstructing, rejuvenating, and regenerating body features. There have been several important advancements in lipomodeling procedures during the last thirty years. Four clinical steps are important for the success of engraftment: fat harvesting, fat processing, fat reinjection, and preconditioning of the recipient site. With the discovery of adipose derived stem cells and dedifferentiated cells, fat cells become a major tool of regenerative medicine. This article reviews recent trends in lipomodeling trying to understand most of the issues in this field.

Autologous Fat Transplantation to the Reconstructed Breast Does not Hinder Assessment of Mammography and Ultrasound: A Cohort Study

BACKGROUND

Autologous fat transplantation (AFT) to the breast can correct defects and be a part of a breast reconstruction to achieve a better aesthetic result. The impact of AFT on the radiological evaluation and detection of cancer remains unclarified. The aim of this study is to investigate whether AFT induces lasting modifications.

METHODS

In the present study, a valuation was performed of 44 breasts from 37 patients examined with mammography and ultrasound before and after autologous fat transplantation. Breast radiologists evaluated the images using a study specific protocol.

RESULTS

AFT did not hinder post-operative assessment of mammograms or ultrasound. No detectable changes with serious clinical impact were found after injections of mean 177 ml (34-516) of fat in one to four sessions. The rate of oil cysts was significantly higher after AFT than pre-operatively (2.3 vs. 34.1 % p = 0.0013). Significantly more post-operative oil cysts were detected after injection of larger volumes of fat (144 vs. 243 ml, p = 0.013). No significant differences were found in the post-operative images regarding age at surgery, follow-up time, or time from previous breast surgery.

CONCLUSION

AFT does not impair assessment of mammograms and ultrasound in patients who have a history of breast cancer surgery or prophylactic mastectomy.

Systematic review: The oncological safety of adipose fat transfer after breast cancer surgery

OBJECTIVES

Oncological concerns have risen around the safety of adipose fat transfer (AFT) after breast cancer surgery. In this article, we present the clinical and molecular evidences, and discuss the current contradiction between them.

MATERIALS AND METHODS

Every clinical trial and experimental study on AFT and its oncological influences was screened. Between September 2014 and September 2016, 856 articles from four databases were found. 105 core articles were selected.

RESULTS

A total of 18 clinical studies have been published. The loco-regional recurrence (LRR) incidence rates range between 0 and 3.90% per year. For the mastectomy and breast conservative therapy group separately, a LRR per year between 0 and 1.62% and 0-3.90 has been reported, respectively. Some studies included a matched control group and found no significant difference between cases and controls, with the exception of a subgroup of patients with intraepithelial breast carcinoma. Adipose derived mesenchymal stem cells have a potential oncogenic effect on residual cancer cells after breast cancer surgery. Numerous signalling proteins and pathways have been described that can stimulate tumour initiation and growth.

CONCLUSION

There is a contradiction between experimental and clinical findings. Numerous adipokines have been discovered that could potentially promote tumour initiation and growth, but clinical studies fail to point out a significant increase in LRR in patients who receive AFT after breast cancer surgery. More prospective studies are needed with a sufficient follow-up time and analysis of some critical factors, such as adjuvant radiotherapy and hormonal therapy, the origin and volume of the injected fat, and genetic influences.

Breast cancer and fat grafting: efficacy, safety and complications-a systematic review

Autologous fat grafting (AFG) or lipofilling is nowadays a popular technique for breast reconstruction after breast cancer surgery. There is debate regarding the oncological safety and risks of this procedure in breast cancer patients. A systematic review of the literature published between January first 1995 and October first 2016 was conducted regarding the efficacy, safety and complications of this technique in breast cancer patients after their cancer treatment. The databases PubMed, Science Direct and Thomson Reuters Web of Science were used to search for qualified articles. Inclusion criteria were women with a personal history of breast cancer and at least one lipofilling procedure. Only studies containing a minimum of 20 patients were included in this systematic review. The search yielded a total of 23 suitable articles: 18 case series, 4 retrospective cohort studies and one prospective cohort study. The systematic review encompassed a total of 2419 patients. Medical imaging was used in the majority of the studies to assess the follow-up. Mammography was the most popular technique (65.2%), followed by ultrasound (47.8%) and MRI (30.4%). The prevalence of complications was the following: fat necrosis in 5.31%, benign lesions, like cysts or calcifications in 8.78%, infections in 0.96% and local cancer recurrence in 1.69%. AFG or lipofilling appears to be an oncological safe technique with a low morbidity in women with a history of breast cancer. In order to have a better understanding and evidence of the oncological safety a randomised controlled trial is urgently needed. We further recommend that all AFG be registered in the cancer register.

Autologous fat transfer to the subcutaneous tissue in the context of breast reconstructive procedures

Autologous fat transfer (AFT) is an appropriate technique for aesthetic rejuvenation of the face, aesthetic enhancement of hands, correction of the facial appearance in various disorders and constitutes a surgical alternative of treatment of numerous breast deformities ranging from distorting posttraumatic scars, post-eczema lesions, post-burn deformities to partial or total breast reconstruction. Our work is aimed to familiarize dermatologists with the technique of harvesting and implanting the aspirate of adipose cells in patients consulted for deformities of the breast. In addition, the review summarizes the most common applications of AFT in the breast reconstructive procedures. In summary, AFT is an oncologically safe, relatively complication-free, minimally invasive surgical technique, which can be used to correct a wide range of deformities, which are commonly seen by dermatologists, in the area of the face, trunk and extremities. The procedure can correct a wide range of breast deformities, from contour or single quadrant deformities up to the state after mastectomy.

The Safety, Effectiveness, and Efficiency of Autologous Fat Grafting in Breast Surgery

Background:

For years, the safety and effectiveness of autologous fat grafting (AFG) for breast reconstruction have been in question, with particular concern over fat necrosis, calcifications, cyst formation, and interfering with the detection of breast cancer. However, increasing evidence suggests that the complication rates and clinical results are generally acceptable to both clinicians and patients. The emerging challenge is the numerous AFG techniques and systems, where there are limited knowledge and data. The objective of this study was to conduct a literature review that focuses on the safety, effectiveness, and efficiency of various AFG techniques as applied to the breast.

Methods:

A PubMed search using terms related to AFG was performed over a 5-year period (April 1, 2010–April 30, 2015). Original articles focused on AFG to the breast, with outcomes on safety, effectiveness, and efficiency, were included.

Results:

Five hundred ninety-eight articles were identified with 36 articles included (n = 4306 patients). Satisfaction rates were high although the prevalence of complications was low—similar to previous findings. Seven studies reported average operating room time with an overall mean of 125 minutes (range: 40–210). The mean volume of fat harvested was 558 mL (range: 120–1299), and fat injected was 145 mL (range: 20–607). A positive association between injection volume and operating time was observed.

Conclusions:

This review validates previous findings on the safety and effectiveness of AFG to the breast and highlights its efficiency. The efficiency data available, although limited, suggest that there is an opportunity to achieve time and cost savings while not sacrificing safety and effectiveness.

The Oncologic Safety of Breast Fat Grafting and Contradictions Between Basic Science and Clinical Studies: A Systematic Review of the Recent Literature

Fat grafting is increasingly popular and is becoming a common practice in plastic surgery for postmastectomy breast reconstruction and aesthetic breast augmentation; however, concerns over the oncologic safety remains a controversial and hot topic among scientists and surgeons. Basic science and laboratory research repeatedly show a potentially dangerous effect of adipose-derived stem cells on breast cancer cells; however, clinical research, although limited, continually fails to show an increase in breast cancer recurrence after breast fat grafting, with the exception of 1 small study on a subset patient population with intraepithelial neoplasm of the breast. The aim of this review is to summarize the recent conflicting basic science and clinical data to better understand the safety of breast fat grafting from an oncological perspective.

Fat grafting for breast cancer patients: From basic science to clinical studies

Fat grafting in the surgical treatment of breast cancer has become popular in a short period of time because of the rising expectations of good esthetic results by the patients as well as the simplicity of the technique; however, the oncological safety for breast cancer patients remains a matter of debate. The procedure raises many questions considering that recent in-vitro studies have shown that fat grafting could promote tumor recurrence through diverse mechanisms, or even facilitate distant metastasis. We present a review of the currently available experimental and clinical data in order to describe and discuss patient selection criteria following breast cancer surgery.

Breast Augmentation by Water-Jet Assisted Autologous Fat Grafting: A Report of 300 Operations

Background  The BEAULI -method (Breast Augmentation by Lipotransfer) is available for extraction and processing of large transplantable fat quantities. The aim of this work is to describe the surgical technique precisely and reproducibly and to provide an overview of the autologous fat transfer based on surgical experience.

Method  The author performed 300 autologous fat transplantations on 254 women between September 3, 2010, and May 13, 2015. Patients desiring moderate volume increase, fuller and firmer breasts, as well as an optimization of the silhouette, ideally with the concurrent desire of the correction of unwanted fat deposits, were selected. The fat was extracted via water-jet assisted liposuction (Body-jet, Human Med AG, Schwerin, Germany), and the fat cells were subsequently separated with the Lipocollector ^® (Human Med AG, Schwerin, Germany).

Results  The results were assessed with a control exam and photo comparison and were based on the responses on a questionnaire. Overall, 35.9% of the patients defined the result as very good, 38.6% as good, 22.4% as satisfactory, and 3.1% as poor.

Conclusion  This study shows that the autologous fat cell transplantation into the female breast via water-jet assisted liposuction achieves a moderate and harmoniously appearing breast volume enlargement as well as contour improvement. Further studies with more cases and longer observation periods over several years could contribute to improving the method of the autologous fat transfer regarding the grow-in rate, efficiency, and safety.