Fat Grafting after Invasive Breast Cancer: A Matched Case-Control Study

Endoscopic mastectomy followed by immediate breast reconstruction with fat grafting for breast cancer

BACKGROUND

Although endoscopic mastectomy has been associated with good tolerance and enhanced patient satisfaction, limitations such as the implant or flap size for reconstruction with small incisions remain unresolved. Fat grafting (FG) can expand tissue volume with pinhole skin incisions. Herein, we evaluated the safety and efficacy of endoscopic mastectomy followed by immediate FG.

METHODS

Patients who underwent endoscopic mastectomy with immediate FG reconstruction from 2015 to 2021 were retrospectively evaluated to establish surgical outcomes and prognosis.

RESULTS

Twenty-three patients with clinical stage 0 or I breast cancer underwent unilateral endoscopic mastectomy with immediate FG. The median age was 45 years (41-55), and the median body mass index was 19.3 kg/m2 (15.8-26.6). Endoscopically performed procedures included skin-sparing mastectomies in 18 patients (78%) and nipple-sparing mastectomies in five patients (22%). The median procedure duration was 295 min (242-346). The median specimen weight was 133 g (71-334), and the median grafted fat volume was 200 mL (136-320). No patient required reoperation or additional procedures for complications. One patient experienced recurrence at a median follow-up of 56.1 months and underwent resection; the patient was alive without recurrence 54 months post-resection.

CONCLUSION

To the best of our knowledge, this is the first report of endoscopic mastectomy with immediate FG for reconstruction. When compared with other immediate autologous reconstructions, our strategy could minimize the skin incision and procedure duration, as well as limit complications. Further prospective investigations are needed to evaluate oncological safety, surgical outcomes, and patient satisfaction.

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.

Association of Fat Graft with Breast Cancer Recurrence in Implant-Based Reconstruction: Does the Timing Matter?

PURPOSE

In two-stage prosthetic breast reconstruction, autologous fat graft (AFG) is often conducted simultaneously with the second-stage operation, which is usually performed shortly after mastectomy. There is a paucity of studies evaluating whether conducting AFG early, with a relatively short interval from the primary operation, is oncologically safe. This study aimed to evaluate potential associations of AFG with breast cancer prognosis, focusing on its timing.

METHODS

Patients with invasive breast cancer who underwent immediate two-stage prosthetic reconstruction following mastectomy between 2011 and 2016 were identified. They were categorized into two groups by whether AFG was performed during the second-stage operation. Cumulative incidence of oncologic events was compared between the two groups, after stratifying patients by the time interval between mastectomy and the second-stage operation (≤ 12 months vs. > 12 months).

RESULTS

Of 267 cases that met the selection criteria, 203 underwent the second-stage operation within 12 months of mastectomy. AFG was performed for 112 cases and was not performed in 91 cases. The two groups showed similar baseline characteristics including tumor stage and adjuvant treatments. Compared with the control, AFG was associated with lower locoregional recurrence-free survival and disease-free survival, and this difference remained significant after adjusting for other variables including tumor stage. In the 64 cases undergoing the operation after 12 months following mastectomy, oncologic outcomes did not differ between the two groups.

CONCLUSION

Our results suggest that AFG timing in relation to mastectomy may be associated with risks for breast cancer recurrence.

Condensing of Low-Density Fat by Mechanical Process Improves Fat Retention and Reduces Oil Cyst Formation in Breast Reconstruction

BACKGROUND

Although autologous fat grafting is a useful adjunct for breast reconstruction, its indications remain limited as large-volume fat grafting results in high absorption and complication rates. Low-density fat includes small numbers of viable cells and considerable oil, resulting in nodules and oil cysts. This study evaluated the volumization effect and complications with combined fat grafting of condense low-density fat and high-density fat.

METHODS

This retrospective, single-center study included 25 patients who underwent combined grafting of condensed low-density fat and high-density fat (CLDF + HDF) and 20 patients who underwent conventional Coleman fat grafting for breast reconstruction from December 2017 to January 2022. Retention rates and complications were evaluated by magnetic resonance imaging and ultrasound rates. Patient satisfaction was evaluated using a typical Likert scale. Photographs were taken and imageological examinations were performed before and after treatment.

OUTCOMES

Graft retention rate was higher in patients who underwent CLDF + HDF than Coleman fat grafting for breast reconstruction (38.40 ± 4.41% vs. 31.43 ± 5.43%, p <0.05). One patient in the CLDF + HDF grafting group, compared with twelve in the Coleman fat grafting group, developed oil cysts exceeding 1 cm. Patient satisfaction rate was higher in the CLDF + HDF grafting group.

CONCLUSIONS

Mechanical processes can concentrate the cellular content of LDF and remove oil, condensing LDF to the level of HDF. Combined grafting of CLDF optimized by mechanical processing and HDF is effective for breast reconstruction, with a higher retention rate and a lower incidence of complications than conventional Coleman fat grafting.

LEVEL OF EVIDENCE IV

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 .

Systematic review: Oncological safety of reconstruction with fat grafting in breast cancer outcomes

BACKGROUND

Autologous fat grafting (AFG) has become a commonly used procedure for breast reconstruction (BR) after cancer removal. Nevertheless, oncological considerations remain for AFG after breast cancer surgery.

OBJECTIVES

This article aims to evaluate the oncological safety of AFG in BR and its effect on disease-free survival (DFS) and local-regional recurrences (LRR).

METHODS

A systematic review regarding the use of AFG in BR to identify a difference in incidence rates of LRR and DFS between patients who had AFG and controls was performed using PubMed, MEDLINE, Embase, PreMEDLINE, Ebase, CINAHL, PsycINFO, Clinicaltrials.gov, Scopus, and Cochrane databases. The protocol was developed following the Preferred Reporting for Items for Systematic Reviews-Protocols (PRISMA-P) guidelines. The included studies had to match predetermined criteria according to the PICOS approach.

RESULTS

A total of 11 studies were included. Seven studies reported LRR, and 5 studies reported DFS in 5,886 patients. Our systematic review showed that AFG was not associated with increased LRR and DFS. Pooled hazard ratios (HRs) (95% confidence intervals [CIs]) for LRR and DFS were 1.26 (0.90-1.76) and 1.27 (0.96-1.69), respectively.

CONCLUSIONS

AFG can, therefore, be performed safely in BR after breast cancer. Further, randomized controlled trials and related systematic reviews, as well as evidence-based medicine (EBM) studies of level 1, are required to consolidate the results of the studies identified in this systematic review.

Reverse Expansion Following Nipple Sparing Mastectomy: A Natural, Safe and Effective Autologous Technique for Breast Reconstruction

The majority of surgeons choose an implant-based breast reconstruction after mastectomy. Nevertheless, lipofilling is a constantly growing technique allowing a complete breast reconstruction without prosthesis. We introduce our experience using reverse expansion for breast reconstruction following a nipple-sparing mastectomy (NSM) with a subpectoral skin expander. In the period January 2010-August 2021, 106 breast reconstruction procedures were performed on 50 patients after a NSM. We harvested an amount of fat tissue using a 2.5 mm liposuction cannula, we centrifuged it 3 min at 4000 rpm and injected in the recipient site using 3 ml syringes and Coleman cannulas. At the beginning of every session, the breast expander was deflated of a saline volume similar to the one of the fat to be injected. We harvested an average of 679.2 ccs of fat per session and injected an average of 319.3 ccs per breast. The mean number of sessions has been 2.4 per breast. The average number of sessions in a radiotreated patients' subgroup has been slightly higher than a control group. The mean follow-up time was 63.5 months and we observed no complications in 105 over 106 procedures. Lipofilling has proven to be a safe and effective technique for complete breast reconstruction. Our procedure considers the use of a breast expander as a device to prepare the recipient site. Reverse expansion after a NSM allows a like-with-like reconstruction and it might be the first reconstructive choice in a selected group of patients.Level of Evidence IV 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 .

Oncological safety of reconstruction with autologous fat grafting in breast cancer patients: a systematic review and meta-analysis

To evaluate the oncological safety of autologous fat grafting and its effect on disease-free survival and local recurrence in breast cancer patients with autologous fat grafting (AFG) reconstruction. A literature search was performed using the Pubmed, Medline, Web of Science, and Cochrane libraries from January 2011 to March 2020, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, to identify all relevant studies involving the application of autologous fat grafting in breast cancer reconstruction procedures. The primary outcome of the meta-analysis was a difference in incidence rates of locoregional recurrence and disease-free survival (DFS) between patients who had autologous fat grafting and controls. A total of 11 studies were included. Eight studies reported local-regional recurrences (LRR) and five studies reported disease-free survival (DFS) in 5,886 patients. Our meta-analysis of all included studies about survival outcomes showed AFG was not associated with increased LRR and DFS. Pooled hazard ratios (HRs) (95% CIs) for LRR and DFS were 1.26 (0.90-1.76) and 1.27 (0.96-1.69), respectively. According to the published literature, autologous fat grafting did not result in an increased rate of LRR and DFS in patients with breast cancer. Autologous fat grafting can, therefore, be performed safely in breast reconstruction after breast cancer.

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction: A Meta-analysis Based on Matched Cohort Studies

BACKGROUND

Autologous fat grafting has become a commonly used procedure for breast reconstruction after breast cancer surgical treatment. Nevertheless, oncological considerations remain concerning autologous fat grafting after breast cancer surgery.

OBJECTIVE

This meta-analysis aimed to summarize the current matched cohort studies and provide high-quality evidence-based conclusions on the oncological safety of fat grafting in breast reconstruction.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. A literature search was performed on August 1, 2021, using PubMed. All relevant matched cohort studies of patients undergoing autologous fat grafting after breast cancer surgery were included. After independently screening the studies and extracting the data, pooled estimates for local and regional recurrence as well as distant metastases were conducted using Review Manager software (RevMan, version 5.3). Outcomes were expressed as odds ratios and 95% confidence intervals.

RESULTS

Seventeen studies involving 7494 patients were included. The observed outcomes indicated that no significant differences existed in the risks of local and regional recurrence or distant metastases between autologous fat grafting and control groups. Also, there was no significant heterogeneity among the studies.

CONCLUSION

This study provided evidence-based conclusions that support the use of autologous fat grafting in breast reconstruction.

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 .

Effects of Breast-Conserving Surgery Combined with Immediate Autologous Fat Grafting on Oncologic Safety, Satisfaction and Psychology in Patients with Breast Cancer: A Retrospective Cohort Study

Purpose

Autologous fat grafting (AFG) is a technique that can improve the appearance of breasts in surgical patients. There are currently few studies on breast-conserving surgery (BCS) combined with immediate AFG, although we believe that it could achieve satisfactory effects. Therefore, the purpose of this study is to observe the effects of BCS combined with immediate AFG on oncologic safety, satisfaction and psychology of breast cancer patients.

Patients and Methods

We retrospectively collected the data of 85 breast cancer patients from February 2018 to October 2018. After screening, 40 patients in AFG group (AG, BCS combined with immediate AFG) and 40 patients in control group (CG, BCS alone) were finally included in the study. The primary outcomes were the survival, tumor recurrence and metastasis, and BREAST-Q score of patients. The secondary outcomes were short and long-term complications, degree of depression and anxiety of patients.

Results

A total of 80 patients were included in the analysis. There was no significant difference in the clinicopathological data between the two groups (P>0.05). The average follow-up time of the two groups was 40.58±2.630 and 40.28±2.679 months. In the analysis of oncologic safety, no patients died in AG and 1 patient died in CG. In addition, there was no significant difference between the two groups in terms of the overall recurrence rate and the distribution of recurrence types (P>0.05). As for satisfaction, the BREAST-Q score of AG was significantly higher than that of CG (57.85±4.833 vs 51.93±5.045, P<0.001). In the secondary outcomes, there was no short-term complication specified in the study; in the long-term complications, the incidence of calcification in AG was not significantly higher than that in CG (P=0.065). In the analysis of depression and anxiety, there was no significant difference between the two groups (P>0.05).

Conclusion

BCS combined with immediate AFG can significantly improve patients’ satisfaction without increasing the risk of death and tumor recurrence. However, it does not seem to play a role in improving the conditions of depression and anxiety.

OUP accepted manuscript

Adipose-derived stem or stromal cells (ASCs) possess promising potential in the fields of tissue engineering and regenerative medicine due to their secretory activity, their multilineage differentiation potential, their easy harvest, and their rich yield compared to other stem cell sources. After the first identification of ASCs in humans in 2001, the knowledge of their cell biology and cell characteristics have advanced, and respective therapeutic options were determined. Nowadays, ASC-based therapies are on the verge of translation into clinical practice. However, conflicting evidence emerged in recent years about the safety profile of ASC applications as they may induce tumor progression and invasion. Numerous in-vitro and in-vivo studies demonstrate a potential pro-oncogenic effect of ASCs on various cancer entities. This raises questions about the safety profile of ASCs and their broad handling and administration. However, these findings spark controversy as in clinical studies ASC application did not elevate tumor incidence rates, and other experimental studies reported an inhibitory effect of ASCs on different cancer cell types. This comprehensive review aims at providing up-to-date information about ASCs and cancer cell interactions, and their potential carcinogenesis and tumor tropism. The extracellular signaling activity of ASCs, the interaction of ASCs with the tumor microenvironment, and 3 major organ systems (the breast, the skin, and genitourinary system) will be presented with regard to cancer formation and progression.

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.

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.

Clinical study of the feasibility, complications, and cosmetic outcomes of immediate autologous fat grafting during breast-conserving surgery for early-stage breast cancer in China

Background

The resection of tumors in small breasts or in areas such as the upper and inner parts of the breast may have disabling cosmetic results. Tumor resection reduces the volume of the breast and may result in asymmetry or distortion of the nipple-areola complex. Autologous fat transfer/grafting has been shown to be a reliable technique for improving these poor cosmetic results. This study aimed to evaluate the feasibility, complications, and cosmetic outcomes of immediate autologous fat grafting during breast-conserving surgery (BCS) in Chinese patients with early-stage breast cancer.

Methods

This retrospective study included 58 patients with early breast cancer treated by the same surgical team from October 2016 to May 2017. The patients were divided into two groups: BCS with lipofilling (experiment group, n=30) and BCS without lipofilling (control group, n=28). All patients received the recommended breast cancer treatment with complementary radiotherapy. The follow-up period after the completion of radiotherapy ranged from 36-44 months. The resected and grafted volumes, complications, esthetic results, patient satisfaction, and recurrence rate within 3 years were compared between the groups.

Results

The average resected and grafted volumes in the lipofilled group were 47 and 74 mL, respectively, with only one seroma and no other complications. Regarding physician evaluation, BCS with lipofilling resulted in better cosmetic outcomes than BCS without lipofilling (33% versus 15%, respectively). Poor responses occurred in only 7% of patients with lipofilling, compared with 15% without lipofilling. Regarding patient self-evaluation, Breast-Q scores including patient satisfaction with their breasts and psychosocial well-being, were significantly higher in patients who received lipofilling compared with non-lipofilled patients. Regional recurrence occurred in one patient (case 21) (3.7%) in the lipofilling group and systemic recurrence occurred in one patient (case 12) (3.8%) in the control group.

Conclusions

Immediate autologous fat grafting is a promising, effective, and convenient technique for partial breast reconstruction after BCS, with potentially higher levels of patient and physician satisfaction compared with traditional BCS.

Trial Registration

Chinese Clinical Trial Registry ChiCTR-ONN-17010514. Registered 24 January 2017.

The Effect of Lipoaspirate Processing Technique on Complications in Autologous Fat Grafting for Breast Reconstruction: A Propensity Score Analysis Study

BACKGROUND

The use of autologous fat grafting (AFG) is becoming increasingly common as an adjunct to breast reconstruction. However, there is a paucity of data comparing the varying processing devices.

OBJECTIVES

The goal of this study was to compare the outcomes of 2 commercially available AFG processing devices.

METHODS

A retrospective review was conducted of patients who underwent AFG with dual-filter (Puregraft) or single-filter (Revolve) processing systems between 2016 and 2019. Propensity score matching was utilized to adjust for confounding. A total of 38 breasts from the Puregraft group were matched with 38 breasts from the Revolve group.

RESULTS

Matching was successful in achieving a similar distribution of baseline characteristics between the 2 groups. The mean number of AFG sessions was comparable between the 2 groups (P = 0.37) with a similar median total volume (Puregraft, 159 mL vs Revolve, 130 mL; P = 0.23). Complication rates were similar between the 2 devices (Puregraft, 26%; Revolve, 18%; P = 0.47). Patients with at least 1 complication had higher overall AFG volume (median, 200 mL vs 130 mL; P = 0.03) and number of sessions (mean, 2.4 vs 1.8, P = 0.009) compared with those without any postoperative complication.

CONCLUSIONS

Overall complication rates were comparable between 2 commonly used, commercially available AFG processing systems, and therefore the choice of which to use should be based on surgeon preference. Future studies are underway to decipher whether either system offers superior graft retention, cosmetic, or patient-reported outcomes.

LEVEL OF EVIDENCE: 3

Palpable Nodules After Autologous Fat Grafting in Breast Cancer Patients: Incidence and Impact on Follow-up

INTRODUCTION

Autologous fat grafting (AFG) is a promising breast reconstruction technique, following surgery. However, fat necrosis after AFG can cause palpable nodules, inducing anxiety and prompting additional investigations. We aimed to determine the occurrence rate and to identify the risk factors of palpable nodules in breast cancer patients prompting complementary explorations.

MATERIALS AND METHODS

We retrospectively reviewed the computerized files of consecutive breast cancer patients who underwent AFG after mastectomy or breast conservative treatment (BCT) at our center from January 2013 to December 2016. We collected data regarding palpable nodule incidences and suspicious breast imaging findings that led to additional explorations.

RESULTS

Of the 252 patients reviewed, 222 (88%) underwent AFG for breast reconstruction, while 30 (12%) underwent AFG for correction of defects after BCT. The follow-up period ranged from 0 to 74 months (median: 27 months), and 201 patients had follow-ups beyond 1 year. Of the 252 patients, 66 (26.2%) underwent at least one control imaging and 24 (10%) underwent a biopsy, including 6 (2.4%) locoregional recurrence. Sixty patients (24%) were diagnosed with nodules during follow-ups. Among them, 52 (87%) patients had additional imaging, and 17 patients (28%) had a biopsy, including 82% benign histology. Patients with BCT had significantly more palpable nodules at 1 year than patients who underwent total mastectomy (odds ratio = 2.50, 95% confidence interval: 1.04. 6.03, p = 0.04).

CONCLUSION

This study underlines the importance of preoperative patient information. This intervention and its follow-up should be reserved for experienced teams to limit unnecessary additional explorations.

LEVEL OF EVIDENCE IV

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 .

Quality and Quantity-Cultured Human Mononuclear Cells Improve Human Fat Graft Vascularization and Survival in an In Vivo Murine Experimental Model

BACKGROUND

Fat graft ischemia impedes us from having satisfying long-term results. The quality and quantity culture is a 1-week cell culture that increases the vasculogenic potential of peripheral blood mononuclear cells (PBMNC). This in vivo murine model investigates whether enrichment with quality and quantity-cultured human mononuclear cells (MNC-QQ) improves the vascularization in the human fat graft and whether this decreases the tissue loss.

METHODS

Human adipose tissue, PBMNC, MNC-QQ, and stromal vascular fraction were prepared. First, PBMNC, MNC-QQ, and stromal vascular fraction were compared in vitro for vasculogenic potential by endothelial progenitor cell colony-forming and culture assays. Second, 0.25-g fat grafts were created with 1 × 106 PBMNC (n = 16), 1 × 106 MNC-QQ (n = 16), 1 × 106 stromal vascular fraction (n = 16), or phosphate-buffered saline as control (n = 16) before grafting in BALB/c nude mice. Grafts were analyzed for weight persistence, vessel formation by CD31 immunohistochemistry, and angiogenic markers by quantitative polymerase chain reaction.

RESULTS

MNC-QQ develop more definitive endothelial progenitor cell colonies and more functional endothelial progenitor cells compared to PBMNC and stromal vascular fraction. Weight persistence after 7 weeks was significantly higher in grafts with MNC-QQ (89.8 ± 3.5 percent) or stromal vascular fraction (90.1 ± 4.2 percent) compared with control (70.4 ± 6.3 percent; p < 0.05). MNC-QQ-enriched grafts had the highest vessel density (96.6 ± 6.5 vessels/mm2; control, 70.4 ± 5.6 vessels/mm2; p < 0.05). MNC-QQ exerted a direct vasculogenic effect through vascular integration and a potential paracrine vascular endothelial growth factor-mediated effect.

CONCLUSION

Quality and quantity-cultured human mononuclear cells containing endothelial progenitor cells stimulate fat graft vascularization and enhance graft survival in a rodent recipient.

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.

Oncologic Safety of Autologous Fat Grafting after Breast Cancer Surgical Treatment: A Matched Cohort Study

BACKGROUND

Autologous fat grafting has been an increasingly popular procedure for remodeling the breast of patients undergoing breast cancer surgery. This study's objective was to investigate whether autologous fat grafting is associated with a higher risk of disease recurrence in the context of late breast reconstruction for patients diagnosed with breast cancer who have undergone either breast-conserving surgery or mastectomy.

METHODS

A retrospective matched cohort study was performed in a single tertiary health care center. Data were collected from 42 patients formerly treated for breast cancer who underwent the first session of autologous fat grafting between August of 2007 and June of 2016. A total of 126 patients with similar features, who did not undergo autologous fat grafting, were individually matched at a 1:3 ratio with the autologous fat grafting group. The primary endpoint was locoregional recurrence. Secondary outcomes were rates of local and distant recurrences, disease-free survival, and overall survival.

RESULTS

At a mean follow-up of 65 months after fat grafting, no significant differences were found between the lipofilling and control groups for locoregional recurrence (7.1 percent versus 6.3 percent; p = 0.856), local recurrence (7.1 percent versus 5.6 percent; p = 0.705), distant recurrence (14.3 percent versus 7.9 percent; p = 0.238), disease-free survival (21.4 percent versus 19.0 percent; p = 0.837), and overall survival (14.3 percent versus 7.1 percent; p = 0.181).

CONCLUSIONS

No evidence of increased risk in any of the survival outcomes was identified. Lipofilling seems to be a safe procedure for breast reconstruction after surgical treatment of breast cancer.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

Oncologic Safety of Autologous Fat Grafting in Breast Reconstruction

Autologous fat grafting is a useful adjunct to breast reconstruction to address contour changes, volume loss, and deformity. More recent benefits observed include mitigation of pain and inflammation. Although there is no clinical evidence to suggest an increased risk in recurrence or new cancer development in fat grafting for breast reconstruction, the oncologic safety of grafting has come into question. Adipose tissue grafts contain progenitor cells and immunomodulatory cytokines, which may induce vasculogenesis or tumor progression or recurrence at the site. Although these are all theoretical concerns, there is a discrepancy between basic science research and clinical outcomes studies. In this review, the authors summarize available literature regarding three important controversies in fat grafting for oncologic breast reconstruction: the interaction of graft component cells, such as adipose-derived stem cells, with cancer cells; the concern of fat grafting interference with breast cancer screening and detection; and clinical evidence regarding the oncologic safety of fat grafting following breast cancer treatment.

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.

Adipose tissue-derived stem cells in breast reconstruction: a brief review on biology and translation

Recent developments in adipose-derived stromal/stem cell (ADSC) biology provide new hopes for tissue engineering and regeneration medicine. Due to their pluripotent activity, paracrine activity, and immunomodulatory function, ADSCs have been widely administrated and exhibited significant therapeutic effects in the treatment for autoimmune disorders, neurodegenerative diseases, and ischemic conditions both in animals and human clinical trials. Cell-assisted lipotransfer (CAL) based on ADSCs has emerged as a promising cell therapy technology and significantly improved the fat graft retention. Initially applied for cosmetic breast and facial enhancement, CAL has found a potential use for breast reconstruction in breast cancer patients. However, more challenges emerge related to CAL including lack of a standardized surgical procedure, the controversy in the effectiveness of CAL, and the potential oncogenic risk of ADSCs in cancer patients. In this review, we summarized the latest research and intended to give an outline involving the biological characteristics of ADSCs as well as the preclinical and clinical application of ADSCs.

Is Autologous Fat Grafting an Oncologically Safe Procedure following Breast Conserving Surgery for Breast Cancer? A Comprehensive Review

BACKGROUND

Autologous fat grafting (AFG) is a recognized surgical procedure to correct deformities following breast conservation surgery (BCS) for breast cancer. However, there are concerns about the oncological safety of this technique. In this study we have reviewed the current literature to assess whether AFG adversely influences the oncological outcome after BCS for breast cancer.

METHODS

We have searched the medical literature using the Embase and PubMed search engines from conception until May 2019 to identify all relevant studies of patients who underwent AFG after BCS. Meta-analysis and meta-regression methodologies were used to calculate the overall relative risk (RR) of loco-regional recurrence (LRR) rates for case-control and case series studies (with historical controls) respectively.

RESULTS

We have identified 26 eligible studies with a total of 1640 patients who had undergone fat transfer after lumpectomy for breast cancer. The meta-analysis of 11 studies revealed an overall RR for LRR of 0.82 [95% confidence interval (CI):0.14-1.66]. The meta-regression of case series revealed an overall incidence of LRR of 1.85% compared with 2.53% for historical controls.

CONCLUSIONS

Our study lends further support to the notion that fat transfer after lumpectomy for breast cancer does not seem to increase the risk of LRR. However further prospective research is required in order to confirm this.

How to Maximize Aesthetics in Autologous Breast Reconstruction

With continuous technical and functional advances in the field of breast reconstruction, there is now a greater focus on the artistry and aesthetic aspects of autologous reconstruction. Whereas once surgeons were most concerned with flap survival and vessel patency, they are now dedicated to reconstructing a similarly or even more aesthetically pleasing breast than before tumor resection. We discuss the approach to shaping the breast through the footprint, conus, and skin envelope. We then discuss how donor site aesthetics can be optimized through flap design, scar management, and umbilical positioning. Each patient has a different perception of their ideal breast appearance, and through conversation and counseling, realistic goals can be set to reach optimal aesthetic outcomes in breast reconstruction.

The safety and efficacy of autologous fat grafting during second stage breast reconstruction

BACKGROUND

Patients often pursue revisions following implant-based breast reconstruction (IBR) to achieve their desired result. Fat grafting is a popular choice for patients and can be performed at second stage reconstruction or at a future date as a revisionary surgery. We investigate the best time to fat graft in IBR by comparing the outcomes of patients who received fat grafting during implant placement with those who pursued fat grafting during a tertiary procedure.

METHODS

We retrospectively reviewed the charts of 157 patients (270 breasts) who underwent immediate two-stage IBR and fat grafting over a five-year period (2012-2016) at our institution. Two cohorts were created based on timing of first fat grafting procedure: immediate (IFG) and delayed (DFG). Charts were reviewed for postoperative complications or revisions.

RESULTS

Complication rates were lower when fat grafting was performed during the second stage (p = 0.0331). Patients in the DFG cohort required more than one additional revision (p < 0.001) until the completion of reconstruction. Patients in the IFG cohort completed their reconstruction and revisions more than one year earlier than the DFG cohort (p < 0.001). Multivariable regressions showed IFG to be associated with decreased revisions (p < 0.001) and total fat grafting procedures (p = 0.008).

CONCLUSIONS

These results indicate that fat grafting at the second stage does not increase overall complication rates, require fewer additional surgeries, and enables patients to reach their desired aesthetic appearance in a shorter time frame. Fewer total surgeries translate not only to a more economical option but also obviate the risk of complications that come with additional surgeries.

Primary Breast Augmentation with Autologous Fat Grafting Alone: Evaluation of Patient Satisfaction Using the BREAST-Q

BACKGROUND

Autologous fat grafting (AFG) for primary aesthetic breast augmentation has grown in popularity over recent years but patient satisfaction has never been objectively evaluated.

OBJECTIVES

The aim of the present study was to use the standardized BREAST-Q questionnaire to evaluate satisfaction in patients who had received primary aesthetic breast augmentation with AFG alone.

METHODS

All recipients of primary aesthetic breast augmentation by AFG performed between 2013 and 2017 in our plastic surgery department were included. The primary endpoint was assessment of patient satisfaction with the standardized breast augmentation BREAST-Q questionnaire. Three additional questionnaires were used to evaluate patient and surgeon satisfaction.

RESULTS

In total, 42 patients (84 breasts) underwent breast augmentation by AFG. Mean patient age was 34 years (range, 23-53 years). The mean volume of reinjected fat was 312.2 mL per breast (range, 130-480 mL). We observed significant improvement in all BREAST-Q postoperative items (excluding physical well-being) with a mean increase of 39 points (95% confidence interval: 28.97, 49.03; P < 0.001) regarding patient satisfaction with breasts. Overall, 82% of patients were satisfied with the result of their liposuction. Minor complications were encountered in 6 of our patients (14%).

CONCLUSIONS

Breast augmentation by AFG enhances patient satisfaction as measured by the BREAST-Q. This procedure has a high satisfaction rate and improves quality of life. Breast augmentation by AFG is a valid surgical option for moderate breast augmentation but is not an alternative to implants in large breast augmentation.

Level of Evidence: 4.

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.

Complications after Breast Augmentation with Fat Grafting: A Systematic Review

BACKGROUND

Breast augmentation with fat grafting is used as an alternative to breast implants. However, a systematic evaluation of the complication rates after fat grafting using only studies with consecutive patients has not previously been performed. In this study, the authors compiled studies reporting complication rates and radiologic changes in consecutive patients undergoing cosmetic breast augmentation with fat grafting.

METHODS

Studies reporting on consecutive patients undergoing breast augmentation with fat grafting were included. Complication rates, radiologic changes, Breast Imaging Reporting and Data System assessments, and the number of patients undergoing revision surgery were extracted. Mean complication rates and radiologic changes were calculated with meta-analytical methods.

RESULTS

Twenty-two studies with 2073 patients were included. The rates of major complications were low (hematoma, 0.5 percent; infection, 0.6 percent; and seroma, 0.1 percent). None of these patients needed revision surgery. The most frequent minor complication was palpable cysts in 2.0 percent of the patients; 67 percent of these were treated with aspiration. The radiologic changes in the patients after fat grafting were as follows: oil cysts, 6.5 percent; calcifications, 4.5 percent; and fat necrosis, 1.2 percent. The risk of being referred for additional radiologic imaging (e.g., to exclude malignant changes) was 16.4 percent, and the risk of being referred for biopsy was 3.2 percent.

CONCLUSIONS

The complication rates after breast augmentation with fat grafting are low and support fat grafting as an alternative to breast augmentation with implants. The rates of radiologic changes are high after fat grafting, but the changes do not seem to have any therapeutic consequences for the patients.

Application of Fat Grafting in Cosmetic Breast Surgery

The role of fat grafting to the breasts has evolved in the recent past, gaining several new applications within both reconstructive and aesthetic surgery. Initially used for reconstructive purposes to fill lumpectomy defects or to correct residual contour deformities after breast reconstruction, it has since made its way into cosmetic breast surgery and has grown to encompass a wide variety of new indications. Fat grafting in aesthetic breast surgery may be performed as a form of primary autologous breast augmentation or as an adjunct to implant-based breast augmentation to disguise implant edges. It may also be used to provide added volume after explant surgery or to provide improvements in breast contour alongside mastopexy techniques. In this article, we will review the current applications of fat grafting in aesthetic breast surgery and provide an up-to-date summary of its reported outcomes, safety, and complications.

Oncologic safety of immediate autologous fat grafting for reconstruction in breast-conserving surgery

IMPORTANCE

Autologous fat grafting (AFG), or lipofilling, has been used for immediate reconstruction at the time of breast-conserving surgery in order to achieve a satisfactory cosmetic outcome in patients with breast cancer and an unfavorable tumor-to-breast volume ratio or unfavorable tumor location. However, the oncologic safety of this technique is still unclear.

OBJECTIVE

To determine whether AFG performed simultaneously with breast-conserving surgery is associated with differences in local relapse rates and disease-free survival.

DESIGN

Matched retrospective cohort study.

SETTING

Tertiary referral center.

PARTICIPANTS

Patients undergoing breast-conserving surgery with or without AFG between 2004 and 2016 were retrospectively enrolled and matched for age, staging, grade, tumor histology, and tumor immunohistochemical profile.

MAIN OUTCOME(S) AND MEASURE(S)

The cumulative incidence of locoregional recurrence (LRR) and disease-free survival were the primary end points, while distant recurrence and overall survival were the secondary end points.

RESULTS

A total of 320 patients were followed. Cases were matched with controls at a 1:4 ratio. There was no difference in LRR or distant recurrence of breast cancer between the two groups. The annual LRR rate was 0.86% in patients who received immediate AFG vs. 0.7% in patients undergoing breast-conserving surgery alone (p ≥ 0.05). Number of lymph nodes was the sole independent risk factor for local recurrence (p = 0.045). No significant differences in disease-free survival rates were found between the groups.

CONCLUSIONS AND RELEVANCE

At a mean follow-up of 5 years, no significant differences in locoregional recurrence rates were found between patients who received immediate AFG and those who underwent breast-conserving surgery alone. These findings corroborate previous research demonstrating the oncological safety of immediate AFG reconstruction, further suggesting that this technique as a safe, effective way to achieve optimal cosmetic outcomes in primary breast cancer surgery without jeopardizing oncologic outcomes.

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.

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.

Latest Trends in Subpectoral Breast Reconstruction

There has been a shift in recent years toward a growing popularity of implant-based breast reconstruction, especially in the setting of increased frequency of concurrent contralateral prophylactic mastectomy. Advancements in implant safety and technology have also allowed for an expanding implant reconstruction practice across the country. The traditional approach is immediate two-stage implant reconstruction with placement of a tissue expander within a subpectoral pocket. The introduction of acellular dermal matrix has revolutionized implant-based breast reconstruction, allowing surgeons the opportunity to minimize morbidity while maximizing aesthetic outcomes. There have also been advances in the management of postoperative pain control as well as secondary revision surgery.

Autogenous Fat Grafting to the Breast and Gluteal Regions: Safety Profile Including Risks and Complications

Given the widespread utility and therapeutic potential of autogenous fat grafting, plastic surgeons should be familiar with its safety profile and associated adverse events. This article provides a critical review of the literature and delineates risk factors associated with various complications when grafting to the breast and gluteal regions. The majority of adverse events are related to fat necrosis and require minimal diagnostic or therapeutic intervention. Larger graft volumes, as in cosmetic augmentation, are associated with higher incidences of fatty necrosis. The oncologic safety of fat grafting is supported by multiple clinical studies with thousands of breast cancer patients, albeit predominantly retrospective in nature. Although less frequent, serious complications include fat emboli during gluteal augmentation. Identification of associated risk factors and implementation of proper surgical techniques may minimize the occurrence of life-threatening complications.

Autologous fat transfer after breast cancer surgery: An exact-matching study on the long-term oncological safety

INTRODUCTION

Autologous fat transfer (AFT) is widely adopted for breast reconstruction, but its long-term oncologic safety is still not clearly established. The aim of the present study was to compare the 10-year loco-regional recurrence (LRR)-free and distant metastases (DM)-free survival probabilities in AFT vs. control patients, also evaluating the impact of AFT in different intrinsic molecular subtypes of breast cancer.

MATERIALS AND METHODS

464 AFT patients were exactly matched with a cohort of 3100 control patients treated between 2007 and 2017. A multivariate survival analysis was performed accounting for all variables related to LRR and DM, including adjuvant/neoadjuvant treatments. End-points were analyzed both overall and in each molecular subtype.

RESULTS

LRR occurred in 6.4% of AFT and in 5.0% of control patients (p = 0.42), while DM were observed respectively in 7.7% and 5.4% of cases (p = 0.20). AFT showed no effect on the 10-year LRR-free survival probability (adjusted HR 0.87, 95%CI 0.43-1.76, p = 0.69) or the 10-year DM-free survival probability (adjusted HR 0.82, 95%CI 0.43-1.57, p = 0.55). Luminal A patients treated by AFT showed a decreased LRR-free survival probability (HR 2.38, 95%CI 0.91-6.17, Log-Rank p = 0.07), which was significantly lower than controls after 80 months (Log-Rank p = 0.02). No differences in the 10-year event-free survival probability were found in Luminal B, HER2-positive or triple-negative patients.

CONCLUSION

AFT does not increase breast cancer recurrence, with the possible exception of late LRRs for Luminal A patients, but further clinical and preclinical data are required to better clarify this data. The use of AFT should not be discouraged.

Novel Assay Analyzing Tropism between Adipose-Derived Stem Cells and Breast Cancer Cells Reveals a Low Oncogenic Response

Introduction

In the surgical world of breast cancer reconstruction, fat grafting is commonly viewed as an oncogenic risk. Scientific studies add confusion, given the stark lack of clinical evidence suggesting pro-oncogenic links. Typically, classic migration assays (e.g., Boyden chamber) between adipose-derived stem cells and breast cancer cells define this cell relationship as pro-oncogenic.

Objective

We sought to develop a new migration model which better explains existing clinical data.

Methods

Silicon chambers were used to seed isolated populations of cells simultaneously in culture dish. Once cells had adhered, chambers were removed and cells were allowed to follow natural trophic cues. Multiple permutations of MDA-MB-231, MCF-7, HS-27, and ASCs were engineered. Cells were stained with MitoTracker for fluorescent visualization. A human cytokine array (RayBiotech) was performed on the media of migrating assays. Cellular tropism and blot intensity were quantitatively measured in Image J.

Results

An in vitro model was successfully constructed where ASCs reproducibly and freely migrated. Cytokine arrays reveal higher levels of IL-6 and CCL2 in the media of Boyden chambers containing ASCs and MDA-MB-231, compared to the novel assay, comprised of the same cell numbers, types, and incubation times.

Conclusion

These data collectively show for the first time the attraction of ASCs to malignant breast cancer cells; a phenomenon which many ASC studies infer. The cytokine profile of the novel system described is less oncogenic than the commonly described Boyden chamber. These data integrate better into the clinical data, which fail to link cancer recurrence with fat grafting.

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.

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.

Effects of Stromal Vascular Fraction on Breast Cancer Growth and Fat Engraftment in NOD/SCID Mice

BACKGROUND

To overcome unpredictable fat graft resorption, cell-assisted lipotransfer using stromal vascular fraction (SVF) has been introduced. However, its effect on cancer growth stimulation and its oncological safety are debatable. We investigated the effect of SVF on adjacent breast cancer and transplanted fat in a mouse model.

METHODS

A breast cancer xenograft model was constructed by injecting 2 × 10⁶ MDA-MB-231-luc breast cancer cells into the right lower back of 40 NOD/SCID mice. Two weeks later, cancer size was sorted according to signal density using an in vivo optical imaging system, and 36 mice were included. Human fat was extracted from the abdomen, and SVFs were isolated using a component isolator. The mice were divided into four groups: A, controls; B, injected with 30 μl SVF; C, injected with 0.5 ml fat and 30 μl saline; group D, injected with 0.5 ml fat and 30 μl SVF. Magnetic resonance imaging and three-dimensional micro-computed tomography volumetric analysis were performed at 4 and 8 weeks.

RESULTS

Tumor volume was 43.6, 42.3, 48.7, and 42.4 mm³ at the initial time point and 6780, 5940, 6080, and 5570 mm³ at 8 weeks in groups A, B, C, and D, respectively. Fat graft survival volume after 8 weeks was 49.32% and 62.03% in groups C and D, respectively. At 2-month follow-up after fat grafting in the xenograft model, SVF injection showed an increased fat survival rate and did not increase the adjacent tumor growth significantly.

CONCLUSION

Fat grafting with SVF yields satisfactory outcome in patients who undergo breast reconstruction surgery.

NO LEVEL ASSIGNED

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.

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.

Modern Primary Breast Augmentation: Best Recommendations for Best Results

LEARNING OBJECTIVES

After reading this article, the participant should be able to: 1. Develop a practical method for preoperative implant size selection. 2. List characteristics and examples of fourth- and fifth-generation silicone implants. 3. Recognize the differences in "profile" designations across implant manufacturers. 4. Recall updated statistics on breast implant-associated anaplastic large cell lymphoma and describe current guidelines on disease diagnosis and treatment. 5. Apply atraumatic and aseptic surgical techniques in primary breast augmentation.

SUMMARY

Modern primary breast augmentation requires an intimate knowledge of the expanding breast implant market, including characteristics of current generation silicone implants and "profile" types. Optimal implant size selection requires balancing patient desires with tissue qualities. Evidence and awareness of breast implant-associated anaplastic large cell lymphoma continue to grow, and patients and surgeons alike should be informed on the most updated facts of the disease entity. Atraumatic surgical technique and aseptic adjuncts are critical in reducing periprosthetic inflammation and contamination, both of which are known instigators of capsular contracture and potentially breast implant-associated anaplastic large cell lymphoma.

Breast-Conserving Surgery with Immediate Autologous Fat Grafting Reconstruction: Oncologic Outcomes

INTRODUCTION

Autologous fat grafting (AFG; lipofilling, lipografting) has been used in delayed breast reconstruction. Recently, it has also been investigated as an alternative for immediate reconstruction in patients submitted to breast-conserving surgery (BCS). Although good aesthetic results have been reported, the oncologic safety of the procedure remains under investigation. This article aims to assess oncologic outcomes of patients submitted to BCS with immediate AFG reconstruction.

METHODS

This study consisted of 65 patients undergoing BCS with AFG between January 2010 and January 2017. They were closely followed after surgery for a median period of 40.8 months. Locoregional and systemic recurrences were the primary endpoints of this study.

RESULTS

Ten patients developed cancer recurrence (15.4%). The median time for recurrence was 58.9 months. Only two patients presented locoregional recurrence (LRR) (3.07%). Five patients had systemic recurrence (7.69%), and three had both systemic and LRR (4.61%). Median disease-free survival (DFS) was 42.2 months, and overall survival (OV) was 44.3 months. Recurrences were significantly associated with the number of metastatic axillary lymph nodes detected.

CONCLUSION

Oncologic outcomes of immediate AFG are similar to the results previously reported in BCS without AFG. Locoregional and systemic recurrences are associated with the presence of axillary metastases.

LEVEL OF EVIDENCE IV

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 .