Fat Grafting to the Breast: Clinical Applications and Outcomes for Reconstructive Surgery

High-Volume Fat Grafting With and Without Goldilocks Mastectomies Show Successful Clinical Outcomes for Breast Reconstruction

ABSTRACT

High-volume fat grafting is an autologous reconstructive technique that provides women with a minimally invasive surgical option, yet there remains a paucity of literature examining details about the reconstructive timeline and outcomes of this procedure. This study presents a retrospective review of a single surgeon's experience performing total autologous breast reconstruction using fat grafting alone or in combination with Goldilocks mastectomies. Our population included 39 breast reconstructions in 25 patients. Nineteen patients (28 breasts) had fat grafting only and 6 patients (11 breasts) had Goldilocks and fat grafting. On comparison, the fat grafting only group averaged 4 grafting sessions while the Goldilocks combined group averaged 2.64 sessions (P = 0.03). In the fat grafting only group, the total average volume of fat injected into each breast was 664 mL, and it was not significantly different from the Goldilocks combined group with 495 mL of fat (P = 0.111). In the fat grafting only group, there was a similar amount of fat injected in the first 5 grafting sessions; following the 5th session, there was a significant drop in volume grafted (P < 0.001). Four fat grafting-related complications were reported (10%) and 3 patients developed seromas following their Goldilocks mastectomies (27%). There were no tumor recurrences. We can conclude from this data that high-volume fat grafting is a successful and safe form of breast reconstruction. We show good volume achieved with minimal procedures necessary, especially when combined with Goldilocks mastectomies. This study depicts a reliable timeline for this autologous and safe reconstructive option.

A combination of fat grafting with inferior dermal flap in breast reconstruction following prophylactic mastectomy: A cohort study

BACKGROUND

Breast reconstruction following prophylactic mastectomy in women with ptotic or hypertrophic breasts often poses challenges. We describe a combined technique of large-volume fat grafting (>100 mL) and an inferior dermal flap, aiming to improve aesthetic outcomes and patient satisfaction.

METHODS

We conducted a retrospective analysis of 21 patients undergoing immediate breast reconstruction with the described technique. All patients were asked to complete the BREAST-Q questionnaire preoperatively and at least 12 months postoperatively (median interval: 20 months). Statistical analysis (Wilcoxon signed-rank test) was used to assess changes in satisfaction and well-being; aesthetic outcomes were scored by an independent, multidisciplinary team.

RESULTS

Among 13 patients with complete BREAST-Q data, satisfaction with the breasts increased significantly from a median score of 38-85 (p = 0.002), psychosocial well-being from 57-70 (p = 0.045), and physical well-being (chest) from 68 to 81 (p = 0.045). Sexual well-being rose from 47-63 (p = 0.023). Aesthetic evaluation by an independent panel showed notable improvements in breast symmetry, shape, and overall appearance. Minimal and asymptomatic fat necroses or oil liponecrotic pseudocysts were observed.

CONCLUSIONS

Combining large-volume fat grafting with an inferior dermal flap appears promising for women with ptotic breasts, yielding high satisfaction and low complication rates. Despite requiring multiple operative stages, this autologous reconstruction technique may offer a less invasive alternative for high-risk patients seeking natural outcomes without implants.

Attenuated Angiogenesis and Macrophage Infiltration during Adipose Tissue Regeneration in Megavolume Human Fat Grafting

BACKGROUND

Survival and regeneration mechanisms of large (>250 mL) fat grafts remain incompletely understood. In fat grafts from volunteers with megavolume fat transfer breast augmentation, neovascularization and inflammatory cell infiltration decreased within 7 days according to histologic analysis. The authors further investigated this phenomenon using a nude mouse model.

METHODS

To simulate clinical contexts, chambers containing 1 mL of human fat were implanted into nude mice. Chambers allowed selective transfer of tissue fluid from recipient nude mice into chambers, but not capillaries or macrophages. Seven days later, fat was removed from the chamber and reimplanted into a new nude mouse in the open-chambered fat group (OCFG) ( n = 45). Adipose samples from volunteers and explanted grafts from OCFG were subjected to histologic analyses. Graft weight, vascularization, and immune response were also compared between the OCFG and conventional direct fat grafting (control group [CG]).

RESULTS

Percentage tissue integrity, percentage fibrosis, adipocyte viability, and neovascularization did not significantly differ between volunteer samples and OCFG grafts at day 7. On day 90, OCFG retention rate was decreased relative to the CG, and the fibrosis area was larger in the OCFG than in the CG. However, the macrophage and capillary counts were lower in the OCFG group relative to the CG at days 7 and 14 after transplantation.

CONCLUSIONS

The present study provides histologic analyses of megavolume fat grafts sampled from clinical breast augmentation tissues and a xenograft nude mouse model. However, these preliminary results in a small clinical cohort should be further assessed in large allogeneic animal models.

CLINICAL RELEVANCE STATEMENT

The results of this study will help surgeons understand the early regeneration of transplanted fat after large volume fat grafting for breast augmentation.

Adipose-derived stem cells enhance the tumorigenic potential of pre-malignant breast epithelial cells through paracrine activation of PI3K-AKT pathway

BACKGROUND

Adipose-derived stem cells (ADSCs)-assisted fat grafting has emerged as a widely used procedure for breast reconstruction post mastectomy and for aesthetic augmentation. Given the limited cases of breast cancer following grafting, the oncological safety of this procedure remains controversial.

METHODS

The effects of ADSCs on the oncogenic features of premalignant MCF-10AT cells were investigated using co-culture and xenograft models. We further evaluated the malignancy-promoting effect of ADSCs in a 7,12-Dimethylbenz(a)anthracene (DMBA)-induced breast cancer model. RNA-sequencing was performed on ADSCs, MCF-10AT cells, and ADSC-co-cultured MCF-10AT cells. Protein changes in ADSC/MCF-10AT co-culture medium and MCF-10AT cells were determined by proteomic analysis. Pathway inhibitors were used to investigate signaling pathways involved in the ADSC-induced oncogenic changes of MCF-10AT cells.

RESULTS

We found that ADSCs promoted the proliferation and migration of MCF-10AT cells, and co-injection of ADSCs increased the tumor incidence of MCF-10AT cells from 29% to 58% in nude mice. Additionally, grafted ADSCs significantly enhanced tumor incidence, growth, and distant metastasis in the DMBA-induced rats, while it could not induce tumorigenesis in normal breast tissues. Combined RNA-sequencing and proteomic analysis demonstrated that the paracrine factors secreted by ADSCs robustly activated the oncogenic PI3K-AKT signaling in MCF-10AT cells. We also revealed the auto-activated TGF-beta and Wnt pathways in co-cultured MCF-10AT cells, which may be synergistic in tumor formation and progression. As expected, blocking these pathways, especially the PI3K-AKT pathway, strongly diminished the promoting effects of ADSCs, suggesting their potential as therapeutic targets for ADSC grafting-associated breast tumors.

CONCLUSIONS

Our data illustrated the synergistic effect between ADSC paracrine factors and MCF-10AT auto-activated pathways in the carcinogenesis of MCF-10AT cells through activation of the oncogenic PI3K-AKT pathway. Based on these findings, we strongly recommend pre-operative examinations for breast cancer risk factors before ADSC-associated transplantation.

Repeated Autologous Fat Grafting Significantly Increases Mastectomy Flap Thickness in Pre-Pectoral Multi-Stage Composite Expander-to-Implant Breast Reconstruction: Exploring the Concept of a Reverse Expansion

Background/Objectives: Combining autologous fat grafting with implant placement is meant to improve the quality of implant-based breast reconstruction. The present study explores the concept of multi-stage composite breast reconstruction with repeated sessions of autologous fat grafting to increase mastectomy flap thickness and provide better pre-pectoral implant coverage. Methods: Twenty-five consecutive patients underwent bilateral multi-stage composite expander-to-implant breast reconstruction and reverse expansion from August 2020 to April 2024. Subcutaneous thickness of the mastectomy flap was evaluated in predefined regions of interests of the breast on standardized MR images at two timepoints (before the first fat grafting session, with the tissue expander fully inflated, and 3 months after implant placement). Furthermore, the incidence of complications requiring surgery and implant-related complications were evaluated. All values are expressed as mean ± standard deviation, accepting statistical significance for a p-value < 0.05. Results: Patients underwent an average of 2.5 ± 0.6 fat grafting sessions, with a fat injection volume of 170 ± 60 mL per breast per session. The mean duration of the reconstructive process from mastectomy to final implant placement was 12 ± 5 months and the mean follow-up was 17 ± 8 months. The overall thickness of both breasts amounted to 190% of baseline thickness and was significantly higher in the upper breast quadrants than in the lower quadrants (p < 0.05). Tissue thickness increase correlated well with the number of fat grafting sessions and was independent of the patient's weight gain. Complications requiring surgery occurred in eight breasts during the reconstruction, with iatrogenic expander puncture being the most frequent (three cases, 6%). During follow-up, only one implant-related complication was observed (one case of bilateral rippling, 4%). No breast animation or symptomatic capsular contracture were observed. Conclusions: Multi-stage pre-pectoral composite expander-to-implant breast reconstruction using autologous fat grafting is an effective concept for breast reconstruction. Despite the need for multiple surgeries, the significant increase in subcutaneous tissue thickness, resulting in better soft tissue coverage, compensates for the longer reconstructive process.

Efficacy of Exclusive Fat Grafting for Breast Reconstruction: An Updated Systematic Review and Meta-analysis

BACKGROUND

Exclusive fat grafting is an alternative method to implant- or flap- based reconstruction techniques following mastectomies or breast conservation therapies. Its efficacy has been explored before but new data has come to light, resulting in previous results becoming outdated. Concerns have also been raised about the oncological safety of this procedure which must be evaluated alongside the efficacy to gain a comprehensive understanding of the merits of this alternative technique.

METHODS

We queried the PubMed electronic database from its inception until August 2023 for studies evaluating the efficacy and oncological safety of exclusive fat grafting breast reconstruction following cancer-related mastectomy or breast conservation therapy. Results of the analysis were pooled and presented as means or valid proportions. Results of the analysis were pooled using a random-effects model and presented with 95% confidence intervals (95% CIs) where appropriate.

RESULTS

41 studies were included in our analysis. Pooled results show that on average, 1.7 sessions of exclusive fat grafting were required to complete reconstruction in Breast Conservation Therapy (BCT) patients, with an average volume of 114.2 ml being injected. For mastectomy patients with irradiated breasts, 4.7 sessions were needed on average with 556.8 ml being required to complete reconstruction, compared to their non-irradiated Counterparts requiring only 2.6 sessions and 207.2 ml to complete reconstruction. Oncological recurrence events were found in 29/583 non-irradiated mastectomy patients (p = 0.014) and in 41/517 BCT patients (p = 0.301) CONCLUSION: Exclusive fat grafting is an oncologically safe and reasonably efficacious alternative to more common methods of breast reconstruction. More data is needed to fully characterize the oncological safety of this procedure in irradiated and non-irradiated mastectomy patients.

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 .

Managing Asymmetry in Breast Reconstruction After Mastectomy-A Systematic Review and Highlight of Clinical Pearls

Background/Objectives: As breast reconstruction techniques continue to progress, patient satisfaction with aesthetic outcomes has become an increasingly important marker of success. Obtaining optimal symmetry often requires secondary procedures whether reconstruction is unilateral or bilateral, implant-based or autologous, immediate or delayed. Consequently, determining the ideal method to achieve symmetry, particularly in challenging scenarios, such as the radiated breast, is nuanced and requires experienced decision-making. Methods: A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement guidelines, including the PubMed, Cochrane Library, and Embase bibliographic databases, to identify original articles addressing asymmetry in both implant-based and autologous breast reconstruction. Studies based on benign breast disease or oncoplastic reconstruction for partial mastectomy/lumpectomy defects were excluded. Results: The search initially yielded a total of six hundred and fifty unique articles. After complete assessment of inclusion and exclusion criteria, a total of forty-one articles were included in total. Conclusions: This article provides a systematic review of the current literature available to guide surgeons on managing asymmetry in breast reconstruction and highlights case examples of frequently encountered clinical challenges. A novel treatment algorithm was then generated to serve as a comprehensive decision-making guide for both patients and surgeons.

Survival Mechanisms and Retention Strategies in Large-Volume Fat Grafting: A Comprehensive Review and Future Perspectives

INTRODUCTION

Large-volume fat grafting is emerging as a promising technique in plastic and reconstructive surgery. However, the unpredictable graft volume retention rate remains a critical challenge. To address this issue, we need a profound understanding of the survival mechanisms following large-volume fat transplantation. This review summarizes known survival mechanisms and strategies to enhance graft retention.

METHODS

This review comprehensively examines the current literature on the survival mechanisms and retention strategies in large-volume fat grafting. A thorough literature search was conducted using PubMed, Medline and Google Scholar databases, focusing on studies published from 2009 to 2023.

CONCLUSION

In the current research on fat survival mechanisms, few have focused on large-volume fat grafting. This review provides an overview of the survival mechanisms specific to large-volume fat grafting and identifies a survival pattern distinct from that of small-volume fat grafting. Additionally, we have summarized existing strategies to improve graft retention across five stages (harvesting, processing, enrichment, grafting and post-graft care), analyzed their advantages and disadvantages and identified some of the most promising strategies.

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.

The effect of exogenous mitochondria in enhancing the survival and volume retention of transplanted fat tissue in a nude mice model

BACKGROUND

Despite the pivotal role of fat grafting in plastic, reconstructive, and aesthetic surgery, inconsistent survival rates of transplanted adipose tissue, primarily due to early ischemic and hypoxic insults, remain a significant challenge. The infusion of healthy mitochondria has emerged as a promising intervention to support tissue recovery from ischemic, hypoxic, and other types of damages across various organ systems.

OBJECTIVES

This study aims to evaluate the impact of supplementing human adipose tissue grafts with healthy exogenous mitochondria on their volume and mass retention rates when transplanted into the subcutaneous layers of nude mice. This approach seeks to improve and optimize fat grafting techniques.

METHODS

Human adipose tissues were preconditioned with exogenous mitochondria (10 µg/mL), a combination of exogenous mitochondria and the inhibitor Dyngo-4a, Dyngo-4a alone, or PBS, and then transplanted into the subcutaneous tissue of 24 nude mice. Samples were harvested at 1 and 3 months post-transplantation for analysis of mass and volume retention. The structural morphology and integrity of the adipose tissues were assessed using Hematoxylin and Eosin (H&E) staining.

RESULTS

Mitochondrial preconditioning significantly enhanced the retention of mass and volume in fat grafts, demonstrating superior structural morphology and integrity compared to the control group.

CONCLUSIONS

This study highlights the potential of exogenous mitochondrial augmentation in fat transplantation to significantly improve fat graft survival, thereby optimizing the success of fat grafting procedures.

Lipolysis inhibition improves the survival of fat grafts through ameliorating lipotoxicity and inflammation

Fat grafting is a promising technique for correcting soft tissue abnormalities, but oil cyst formation and graft fibrosis frequently impede the therapeutic benefit of fat grafting. The lipolysis of released oil droplets after grafting may make the inflammation and fibrosis in the grafts worse; therefore, by regulating adipose triglyceride lipase (ATGL) via Atglistatin (ATG) and Forskolin (FSK), we investigated the impact of lipolysis on fat grafts in this study. After being removed from the mice and chopped into small pieces, the subcutaneous fat from wild-type C57BL/6J mice was placed in three different solutions for two hours: serum-free cell culture medium, culture medium+FSK (50 μM), and culture medium+ATG (100 μM). Following centrifugation to remove water and free oil droplets, 0.3 mL of the fat particles per mouse was subcutaneously injected into the back of mice. Additionally, the subcutaneous fat grafting area was immediately injected with PBS (control group), ATG (30 mg/kg), and FSK (15 mg/kg) following fat transplantation. Detailed cellular events after grafting were investigated by histological staining, real-time polymerase chain reaction, immunohistochemistry/immunofluorescent staining, and quantification. Two weeks after grafting, grafts treated with ATG showed lower expression of ATGL and decreased mRNA levels of TNFα and IL-6. In contrast, grafts treated with ATG showed elevated expression levels of IL-4 and IL-13 compared to the control grafts. In addition, fewer apoptotic cells and oil cysts were observed in ATG grafts. Meanwhile, a higher CD206+/CD68+ ratio of macrophages and more CD31+ vascular endothelial cells existed in the 2-month ATG grafts. In comparison to the control, ATG treatment improved the volume retention of grafts, and decreased graft fibrosis and oil cyst formation. By preventing oil droplet lipolysis, pharmacological suppression of ATGL shielded adipocytes from lipotoxicity following grafting. Additionally, ATG ameliorated the apoptosis and inflammation brought on by adipocyte death and oil droplet lipolysis in grafted fat. These all indicate that lipolysis inhibition improved transplanted fat survival and decreased the development of oil cysts and graft fibrosis, offering a potential postoperative pharmacological intervention for bettering fat grafting.

Cyclic High Negative-Pressure External Volume Expansion Reduces Daily Device Application Time With Similar Effects on Recipient Site Preparation in a Murine Model

Introduction: Recipient site preparation using external volume expansion (EVE) increases graft survival in large-volume fat grafting. To improve patient compliance with using the device, we tested a new cyclic high negative-pressure (CHNP) mode that involves 1 h/day at -55 mm Hg, cycled between 1-second negative-pressure activation, followed by a 2-second deactivation period in an animal model. Material and Method: A miniaturized EVE device was applied to 30 8-week-old male Sprague-Dawley rats. The rats were assigned to 3 groups (no pressure for the control group, conventional -25 mm Hg for 8 h/day for conventional EVE, and CHNP mode for the CHNP group). After 28 days, micro-computed tomography was performed and skin biopsy specimens were obtained. Results: The CHNP group showed a 6.6-fold increase and the conventional EVE group showed a 4.4-fold increase in volume compared to the control group. Hematoxylin and eosin staining showed a similar increase in subcutaneous tissue thickness in both EVE groups, compared to the control group. Masson's trichome and proliferating cell nuclear antigen staining showed significantly higher collagen deposition and subdermal adipocytes in EVE groups. Immunohistochemistry against platelet endothelial cell adhesion molecule 1 showed 2.5- and 2.7-times higher vessel density in the conventional and CHNP EVE groups, respectively. There was no statistically significant difference in subcutaneous tissue thickness, collagen deposition, subdermal adipocyte proliferation, and vessel density between the 2 EVE groups. Conclusion: CHNP produced comparable results in recipient site preparation (subcutaneous tissue thickening and angiogenesis) compared to the conventional protocol, while markedly reducing the daily wear-time from 8 hours to 1 hour. Although further clinical data must be acquired, our new pressure setting seems promising and provides a more patient-friendly pre-expansion environment.

[Breast implant removal and simultaneous aesthetic optimization : Possibilities, technical considerations and outcome analysis]

BACKGROUND

Breast augmentation is currently the leading aesthetic surgical procedure worldwide. Thus, there is a high prevalence of women with breast implants demanding serious know-how and expertise concerning long-term complication management. Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. The authors of this article have also been confronted more and more with the unspecified complex of symptoms named breast implant disease (BID), also called breast implant illness (BII). The treatment of choice for BID is implant removal.

OBJECTIVE

Analysis of problems and solutions regarding implant removal. Specific patient analysis according to patients' breast and body configuration. Technical considerations for surgery and preoperative planning. Evaluation of the authors' techniques.

PATIENTS AND METHODS

Evaluation of all patients over a period of 3 years requesting implant removal after esthetic augmentation mammoplasty at the authors' department. All patients were treated according to their specific demands regarding breast shape after implant removal. They either received additional mastopexy, lipofilling or both or simple implant removal without further intervention. Demographic, implant-specific, perioperative and postoperative data have been evaluated for all patients. Additionally, all patients were asked to complete a questionnaire regarding satisfaction and outcome.

RESULTS

We observed a trend for more satisfied patients with less invasive procedures (simple implant removal or simultaneous lipofilling vs. explantation and mastopexy ± lipofilling, 1.8 vs. 2.0 or 2.6, p = 0.198). Patients' average scoring was better if they suffered from an implant rupture (1.55 vs. 2.17, p = 0.053). Overall, a high patient satisfaction has been observed for all procedures.

CONCLUSION

Breast implant carriers can suffer from problems and pathologies making implant removal the best solution. Exactly these patients, consulting their doctor for those problems and questions seem to profit from implant removal. Simultaneous lipofilling and mastopexy of the breast are good options to nevertheless generate an esthetically pleasing result.

Timing of autologous fat grafting in implant-based breast reconstruction: Best practices based on systematic review and meta-analysis

BACKGROUND

Fat grafting is commonly undertaken as a third-stage procedure in patients with staged implant-based breast reconstruction (IBR). However, fat grafting performed during second-stage expander/implant exchange provides faster results without an additional procedure and associated risks (Patel et al., 2020). We previously demonstrated that fat grafting during second-stage expander/implant exchange did not increase clinical complications (Patel et al., 2020). As a corollary, this study investigates patients' satisfaction with second- versus third-stage fat grafting to help establish a set of best practices for the timing of fat grafting in such patients.

METHODS

A review of PubMed/MEDLINE databases (2010-2022) was performed to identify articles investigating the quality of life in patients undergoing second- or third-stage fat grafting after IBR. BREAST-Q scores were pooled using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

RESULTS

Six studies (216 patients) were included. Pooled random-effects modeling demonstrated no significant changes in BREAST-Q satisfaction with outcome scores when comparing patients who received second- versus third-stage fat grafting (p = 0.178) with results robust to sensitivity analyses. In addition, pooled analyses of the available data demonstrated that second-stage fat grafting did not increase downstream revision surgery needs compared to third-stage fat grafting.

CONCLUSIONS

In combination with our prior work, this meta-analysis suggests that second-stage fat grafting provides not only equivalent but improved clinical and quality of life outcomes with fewer procedures in patients undergoing expander/IBR.

Breast Explantation With Simultaneous Mastopexy and Volume Restoration: An Analysis of Clinical Outcomes and Prospective Quality of Life

BACKGROUND

An increasing number of patients are undergoing explantation to alleviate symptoms attributed to the presence of a prothesis or dissatisfaction with the appearance of their breasts.

OBJECTIVES

The authors aim to evaluate the clinical effectiveness and quality of life (QoL) of simultaneous explantation, capsulectomy, and mastopexy for patients requesting implant removal.

METHODS

Two hundred sixty-two simultaneous explantation, capsulectomy, and mastopexy (ECM) procedures were performed in 131 patients from 2009 to 2019. Prospective QoL assessment was administered for all patients. Inclusion criteria included a minimum postoperative follow-up of 6 months and completion of a practice-generated patient reported outcomes (PRO) questionnaire. Wilcoxon signed-rank test was performed to compare changes in QoL scores.

RESULTS

Mean follow-up and BMI were 23 months (6 months to 8 years) and 24.8 kg/m2 (18-34 kg/m2), respectively. Mean age was 48.3 years (26-75 years). Autologous fat grafting was performed simultaneously in patients 47.3% (n = 62). The complication rate was 3.8% (n = 10 breasts) in 9 patients (6.9%). The overall reoperation rate was 7.3% of procedures (n = 19 breasts) and 9.2% of patients (n = 12), including secondary autologous fat grafting (11.3%, n = 7). PRO results demonstrated a significant improvement in all QoL domains, including physical well-being (P < .005), psychological well-being (P < .005), sexual well-being (P < .005), breast shape (P < .005), and breast appearance (P < .005). With respect to breast implant illness symptoms, 59 patients (88.1%) noted reduced pain, myalgias/arthralgias, and fatigue after ECM.

CONCLUSIONS

This study presents an effective paradigm to manage implant removal through simultaneous explantation, capsulectomy, and mastopexy with acceptable clinical outcomes and a significant improvement in QoL and breast aesthetics.

LEVEL OF EVIDENCE: 4

Patient-Reported Outcomes After Autologous Fat Grafting in Prosthetic Breast Reconstruction: Prospective Cohort Study Using a Multivariate Analysis

INTRODUCTION

There is widespread recognition of the importance of assessment of patient satisfaction and well-being after breast reconstruction. However, few studies of fat grafting performed simultaneously with implant-based breast reconstruction (IBBR) have accounted for confounding factors, such as patient background and information bias. The aim of this study was to examine patient satisfaction and well-being using multivariate analysis of BREAST-Q scores in patients treated with IBBR combined with fat grafting.

METHODS

Seventy-one consecutive patients who underwent IBBR with silicone breast implants were enrolled for a prospective cohort study. Among these patients, 56 responded to the BREAST-Q questionnaire, including 24 who underwent fat grafting at the same time as IBBR (FAT+ group) and 32 who underwent IBBR alone (FAT- group). The BREAST-Q questionnaire was completed 1 year after surgery. Statistical analysis was performed using descriptive and summary statistics to identify differences between the 2 groups.

RESULTS

Logistic regression analysis showed that the FAT+ group was significantly more likely than the FAT- group to have satisfaction with breasts (P = 0.0201) and satisfaction with outcome (P = 0.0364).

CONCLUSIONS

Multivariate analysis with consideration of confounding factors indicated that addition of fat grafting to IBBR improves outcomes of breast reconstruction. These results suggest that a minor surgical procedure of fat grafting can improve patient satisfaction and outcomes after breast reconstruction.

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 .

Review of Autologous Fat Grafting in Postmastectomy Reconstruction Patients: Nonroutine Diagnostics and Oncologic Safety

Autologous fat grafting (FG) is increasingly used as an adjunctive reconstruction technique to augment volume, achieve symmetry, and improve contour deformities. This study aims to characterize the oncologic and surgical safety of FG in women undergoing autologous breast reconstruction (ABR) or implant-based reconstruction (IBR).

Methods

A retrospective chart review was performed for all patients undergoing FG at a multi-site single health system between 2015 to 2018. A total of 228 eligible breasts from 155 patients were identified using Current Procedural Terminology codes. Patients were divided by reconstructive technique. Bivariate analyses compared baseline characteristics and post-FG outcomes.

Results

Mean age for patients undergoing ABR (129 breasts) was 52.8 years compared to 48.6 years for those undergoing IBR (99 breasts; P = 0.002). A heavier volume of fat was grafted per ABR breast (143.8mL) than per IBR breast (102.2mL; P = 0.002). Forty-seven (20.6%) breasts required FG revision, more frequently in ABR breasts (31.0%) than IBR breasts (7.1%; P < 0.001). Following FG, 17.5% of patients experienced a palpable mass, and 18.9% of breasts underwent nonroutine diagnostics or procedures, with no difference between ABR and IBR groups. Most biopsies noted benign findings such as fat necrosis (2.2%) or a benign mass (0.9%), with recurrence only noted in two patients (0.9%). Mean follow-up was 20.4 months.

Conclusion

FG is a safe, surgically simple procedure more commonly performed in ABR breasts. FG use in ABR and IBR breasts is oncologically safe, with no impairment in breast surveillance and low rates of locoregional recurrence, but possibly increased incidence of nonroutine imaging and biopsies.

Retropectoral Fat Graft Survival in Mammoplasty: Evaluation by Magnetic Resonance Imaging

BACKGROUND

Fat grafting is used in combination with mammoplasty to improve filling of the upper pole of the breasts. Its effectiveness remains in question due to unpredictable results. Difficulty in isolating the grafted fat and differentiating it from host tissues may hinder assessment of graft integration. The plane between the pectoral muscles is free of fat and has already been described with respect to placement of breast implants and fat grafting in breast surgeries. This study sought to evaluate via magnetic resonance imaging (MRI) the integration and retention of retropectoral fat grafts in mammoplasty.

METHODS

Thirty patients with breast flaccidity who desired to undergo mammoplasty were selected. Fat collected from the abdomen was separated by sedimentation and transferred to the retropectoral region after undermining of the breast and resection of excess tissue. The patients underwent MRI preoperatively and at three and six months after surgery. Fat volumes were calculated by multiplying the values for the major vertical, horizontal, and anteroposterior axes by the constant 0.523.

RESULTS

Twenty-five patients completed the study. The mean volume grafted was 116.4 ± 22.5 ml per breast. Six months after surgery, the mean fat graft volume in the retropectoral plane was 48.1 ± 25.71 ml, and the integration rate was 40.82% (range, 32.2-49.4%). The rate of complications related to fat grafting was 8%.

CONCLUSIONS

In mammoplasty, retropectoral fat grafting showed good integration rates and is a safe and predictable approach that can contribute to improving the outcomes of aesthetic and reconstructive breast surgeries.

LEVEL OF EVIDENCE IV, COHORT ANALYTIC STUDY

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 .

Hybrid Prepectoral Direct-to-Implant and Autologous Fat Graft Simultaneously in Immediate Breast Reconstruction: A Single Surgeon's Experience with 25 Breasts in 15 Consecutive Cases

BACKGROUND

The direct-to-implant method depends on the quality of the mastectomy flaps and can be used only when the flaps are adequately perfused. Even though the method was designed to be a definitive reconstruction procedure, it has been associated with an increased likelihood that additional operative revision will be required in order to achieve the expected final cosmetic outcome. The authors describe a hybrid prepectoral direct-to-implant method that combines autologous fat grafting in the superior medial pole with immediate reconstruction.

METHODS

In this prospective study, 15 patients (25 reconstructed breasts) underwent simultaneous hybrid prepectoral direct-to-implant reconstruction together with autologous fat grafting performed by a single senior plastic surgeon (Y.G).

RESULTS

The mean quantity of autologous fat grafted in the superior medial aspect of the breast was 59.4 ± 12.8 cc. The mean total volume of the hybrid reconstructed breast, including implant and autologous fat graft, was 497.2 ± 89.1 cc. Satisfying final outcomes were achieved in all cases. There were no major complications, although minor complications were observed.

CONCLUSIONS

The authors' hybrid approach allows the surgeon to achieve a more satisfying outcome with regard to the cleavage area. It results in a better natural appearance, an improved contour, and reduced upper pole rippling and deflation, with a lower likelihood that an additional operative revision will be required to achieve the desired final aesthetic outcome. The authors believe that their hybrid approach should be implemented as an integral part of the direct-to-implant prepectoral reconstruction procedure.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Ear reconstruction research using animal models: The effect of fat grafting on costal cartilage stents

OBJECT

For congenital microtia patients with a depressed mastoid area, it is unclear whether autologous fat grafting to fill the depressed area of the cheek will affect the survival of the subsequent grafted costal cartilage stent. An animal model was used for in vivo research to provide guidance for clinical applications.

METHODS

Autologous costal cartilage was implanted in nude mice. Fat samples were collected at different time points and histological examination performed to analyze the activity of chondrocytes and the deposition of the chondrocyte matrix.

RESULTS

This nude mouse fat transplantation model study showed that there were statistical differences in chondrocyte viability between the fat filling group and the control group, but there was no statistical difference in the effect on collagen content.

CONCLUSION

Transplanting fat reduces the viability of chondrocytes, but has little effect on collagen matrix deposition.

Effects of radiation on toxicity, complications, revision surgery and aesthetic outcomes in breast reconstruction: An argument about timing and techniques

BACKGROUND

Radiotherapy (RT) combined with breast reconstruction can reduce the risk of cancer recurrence and increase the survival rate. However, this approach seems to worsen aesthetic outcomes and increase complication rates. The impact of breast reconstruction timing and techniques on clinical outcomes, however, remains unclear. For this reason, we aimed to perform a more comprehensive analysis of a series of patients undergoing RT and breast reconstruction.

METHODS

Patients were divided into 4 groups according to the timing of reconstruction (before RT and after RT) and surgical technique (heterologous reconstruction and autologous reconstruction (AR)). The median time between RT and reconstruction, number of revision surgeries, incidence of complications, toxicity, aesthetics and associated clinical risk factors were used to assess the clinical outcomes. An objective system of skin toxicity evaluation was performed.

RESULTS

Ninety-five patients were included in this study. No significant differences in the median time between RT and reconstruction, incidence of complications, toxicity or aesthetics were noted between different timings or techniques of reconstruction. Patients undergoing AR needed more revision surgeries to complete reconstruction. However, the total number of surgical procedures was similar between the groups. In a comparison between the treated and untreated breasts by an objective system, RT produced an increase in erythema and pigmentation and a decrease in elasticity in the treated breast (p<0.05 for all parameters). On multivariate analysis, smoking was a significant predictor associated with complications.

CONCLUSIONS

Combined breast reconstruction and RT seem to be successful regardless of the order of treatment or the type of reconstruction.

Senescence of donor cells impairs fat graft regeneration by suppressing adipogenesis and increasing expression of senescence-associated secretory phenotype factors

Background

Fat grafting has been regarded as a promising approach for regenerative therapy. Given the rapidly aging population, better understanding of the effect of age on fat graft outcomes and the underlying mechanisms is urgently needed.

Methods

C57/BL6 mice [old (O, 18–20-month-old) and young (Y, 4-month-old)] were randomized to four fat graft groups [old-to-old (O-O), young-to-young (Y-Y), old-to-young (O-Y), and young-to-old (Y-O)]. Detailed cellular events before and after grafting were investigated by histological staining, RNA sequencing, and real-time polymerase chain reaction. The adipogenic differentiation potential of adipose-derived mesenchymal stem cells (AD-MSCs) from old or young donors was investigated in vitro. Additionally, adipogenesis of AD-MSCs derived from old recipients was evaluated in the culture supernatant of old or young donor fat tissue.

Results

After 12 weeks, the volume of fat grafts did not significantly differ between the O-O and O-Y groups or between the Y-Y and Y-O groups, but was significantly smaller in the O-O group than in the Y-O group and in the O-Y group than in the Y-Y group. Compared with fat tissue from young mice, senescence-associated secretory phenotype (SASP) factors were upregulated in fat tissue from old mice. Compared with the Y-O group, adipogenesis markers were downregulated in the O-O group, while SASP factors including interleukin (IL)-6, tumor necrosis factor-α, and IL-1β were upregulated. In vitro, AD-MSCs from old donors showed impaired adipogenesis compared with AD-MSCs from young donors. Additionally, compared with the culture supernatant of young donor fat tissue, the culture supernatant of old donor fat tissue significantly decreased adipogenesis of AD-MSCs derived from old recipients, which might be attributable to increased levels of SASP factors.

Conclusions

Age has detrimental effects on fat graft outcomes by suppressing adipogenesis of AD-MSCs and upregulating expression of SASP factors, and fat graft outcomes are more dependent on donor age than on recipient age. Thus, rejuvenating fat grafts from old donors or banking younger adipose tissue for later use may be potential approaches to improve fat graft outcomes in older adults.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-021-02383-w.

Large-Volume Autologous Fat Grafting to the Breast

Autologous fat grafting in the setting of breast augmentation and reconstruction has become globally accepted and routinely performed. There is general consensus that small-volume grafting is reproducible and predictable; however, large-volume fat grafting (>100 mL) is less predictable and is not as commonly performed. The aim of this article was to review outcomes following large-volume and megavolume fat grafting in the setting of breast augmentation and reconstruction. Level of Evidence: 4.

Postirradiation Capsular Contracture in Implant-Based Breast Reconstruction: Management and Outcome

BACKGROUND

Implant-based breast reconstruction is commonly avoided in the setting of radiation therapy, mainly because of risks of capsular contracture. Nevertheless, as breast reconstruction is becoming more available, more patients undergo both implant-based breast reconstruction and radiotherapy. The dilemma is how to manage capsular contracture if it does occur. The goal of this study was to examine the outcome of patients with implant-based breast reconstruction who developed postirradiation capsular contracture and were treated with capsulotomy or capsulectomy, with or without fat grafting.

METHODS

The authors reviewed charts of patients who developed capsular contracture following alloplastic breast reconstruction followed by radiation therapy, between 2008 and 2018. The surgical treatment methods for capsular contracture were evaluated along with their outcomes. A follow-up of at least 1 year was required.

RESULTS

Forty-eight breasts with postirradiation capsular contracture underwent surgical implant exchange with capsular release, of which 15 had combined fat grafting and 33 did not. Overall, 35 breasts (72.9 percent) showed long-term resolution of capsular contracture; 24 underwent a single procedure and 11 required an additional fat grafting procedure. Some patients [six breasts (12.5 percent)] were offered a consecutive round of fat grafting, and some [seven breasts (14.5 percent)] were offered autologous reconstruction because of lack of improvement. Fat grafting increased the success rate by more than 30 percent when it was initially and consecutively used.

CONCLUSIONS

Postirradiation capsular contracture may be treated successfully by secondary procedures, sustaining implant-based breast reconstruction in over 70 percent of breasts. Fat grafting may elevate resolution rates even further, to 86 percent. Larger prospective studies are required to validate these findings.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Necroptosis in Macrophage Foam Cells Promotes Fat Graft Fibrosis in Mice

Background: Fibrosis is a major grafting-related complication that leads to fat tissue dysfunction. Macrophage-induced inflammation is related to the development of fat tissue fibrosis. Necroptosis is a recently discovered pathway of programmed cell necrosis that results in severe inflammation and subsequent tissue fibrosis. Thus, in this study, we investigated the role of macrophage necroptosis in fat graft fibrosis and the underlying mechanisms.

Methods: Fibrosis and necroptosis were investigated in mouse fat tissue before and after grafting. An in vitro “crown-like” structure (CLS) cell culture model was developed by co-culturing RAW 264.7 macrophages with apoptotic adipocytes to reproduce in vivo CLS macrophage-adipocyte interactions. Lipid uptake and necroptosis in CLS macrophages were analyzed using Oil-Red-O staining, western blotting, and immunofluorescence. RAW264.7 macrophages were cultured alone or with apoptotic adipocytes and treated with a necroptosis inhibitor (Nec-1 or GSK872) to explore the paracrine effect of necroptotic CLS macrophages on collagen synthesis in fibroblasts in vitro. Mice were treated with Nec-1 to analyze the effect of blocking necroptosis on fat graft fibrosis.

Results: Fibrosis was increased after grafting in fat grafts of mice. Macrophages clustered around apoptotic adipocytes or large oil droplets to form a typical CLS in fibrotic depots. This was accompanied by formation and necroptosis of macrophage foam cells (MFCs) in CLSs. RAW 264.7 macrophages co-cultured with apoptotic adipocytes induced CLS formation in vitro, and lipid accumulation in CLS macrophages resulted in the formation and necroptosis of MFCs. Necroptosis of MFCs altered the expression of collagen I and VI in fibroblasts via a paracrine mechanism involving inflammatory cytokines/chemokines, which was reversed by GSK872 or Nec-1 treatment. Furthermore, treatment with Nec-1 ameliorated fat graft fibrosis in mice.

Conclusion: Apoptotic adipocytes induced necroptosis of MFCs, and necroptosis of these cells activated collagen synthesis in fibroblasts via a paracrine mechanism. Inhibition of necroptosis in macrophages is a potential approach to prevent fibrosis in fat grafts.

Oncological outcomes of lipofilling in breast reconstruction: a matched cohort study with 250 patients

Background

Fat grafting is a procedure commonly used in breast reconstruction nowadays. Nevertheless, its oncological safety remains controversial. The potential risk that progenitor cells included in fat graft tissue may contribute to disease progression in patients with breast cancer is still debatable. We have designed a matching-cohort study with 250 patients with history of breast cancer trying to elucidate an answer for this question.

Methods

We selected 250 patients with a history of breast cancer in our hospital, between 2011 and 2019. A total of 125 patients (cases) had a history of breast cancer reconstructed with fat grafting. The additional 125 patients are matched controls. We analyzed the distribution of eight different variables within the cases and their matched controls: date of first oncological surgery, age, type of oncological surgery, histological subtype, Her-2 status, pN, smoking habit and diabetes mellitus. The objective of this study was to analyze the influence of fat grafting over breast cancer recurrence.

Results

There are not statistically significant differences in breast cancer locoregional recurrences (P=0.183), distant metastases (P=0.200) or total recurrences (P=0.065) amongst the two groups (cancer cases and matched controls).

Conclusions

Our study adds more information over the oncological safety of fat grafting. These findings should encourage long-term prospective trials to provide surgeons with accurate information regarding the role of lipofilling on breast neoplasms.

Efficacy and Safety of Subcutaneous Temporal Autologous Micro-fat Augmentation

BACKGROUND

Autologous fat grafting is a rapidly developing soft tissue filling technique that has been playing an increasingly important role in facial contouring and rejuvenation surgeries. However, this technique is accompanied by many side effects and risks. In particular, there is still much room for improvement in regard to the surgical method of temporal augmentation with autologous fat, which is highly popular among Chinese people. Better surgical methods can achieve better outcomes while curbing surgical risks.

DESIGN AND METHODOLOGY

We reviewed 39 patients who consecutively underwent subcutaneous temporal autologous micro-fat argumentation surgery at Peking University People's Hospital from February 19, 2016, to May 13, 2019, to correct temporal hollowness. Each patient's Visual Analogue Scale (VAS) satisfaction score and Hollowness Severity Rating Scale (HSRS) score before and after surgery were precisely recorded, and any complaints about perioperative complications were meticulously collected to assess the efficacy and safety profile of the novel technique.

RESULTS

All 39 patients included in this study were female. We performed 86 subcutaneous temporal autologous micro-fat argumentation surgeries, with an average follow-up of 20.4 ± 9.6 months. The average fat filling volume in the right temporal region was 6.29 ± 2.55 mL, and that in the left temporal region was 6.34 ± 2.71 mL. The average VAS satisfaction score increased from 4.44 ± 1.33 before the surgery to 8.08 ± 0.77 after the surgery, and the average HSRS score dropped from 1.82 ± 0.72 before the surgery to 0.36 ± 0.49 after the surgery. Four patients were encountered with minor complications of intraoperative bleeding and congestion, which were all completely ameliorated after conservative therapies.

CONCLUSION

In the present study, we found that the reported surgical method of subcutaneous temporal autologous micro-fat augmentation successfully improved the temporal hollowness of the patients, boasting good surgical results and high patient satisfaction with minimal short- and long-term complications, illustrating that it is an effective, safe and promising novel surgical technique worthy of wider clinical application.

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 .

Total breast reconstruction using large-volume condensed and viable fat grafting after mastectomy

Autologous fat grafting (AFG) has become a third alternative for breast reconstruction after mastectomy. However, total breast reconstruction using AFG remains a great challenge. We performed breast reconstruction using large-volume condensed and viable fat grafting in 30 postmastectomy patients (irradiated, n = 9; nonirradiated, n = 21). The grafts were purified and condensed by the washing and cotton gauze rolling technique. The surgical maneuver is designed to preserve the grafts viability. Three-dimensional expansion was applied where strong adhesions were present. Seven patients wore the Brava device for the expansion of the recipient site. The mean (SD) volume of fat grafted in each procedure was 230.5 (57.8) mL. The average number of sessions was 3.3 (0.7). The irradiated patients required more sessions than the nonirradiated patients (p=.017). The mean follow-up period was 12.8 (4.3) months. One patient (3%) developed postoperative cellulitis. Cysts and palpable nodules occurred in eight patients (27%) and one patient (3%), respectively. Severe dermatitis and skin pigmentation change occurred in one patient wearing the Brava device. The esthetic scores significantly improved after the treatments (p<.001). Approximately 90% of the patients were satisfied. No local recurrence or remote metastasis was documented during the follow-up period. Our study showed the success of total breast reconstruction using AFG. As a third alternative for breast reconstruction, total breast reconstruction using large volume condensed and viable fat grafting is an effective and safe approach for postmastectomy patients.

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.

Secondary "Hybrid Reconstruction" Concept with Silicone Implants After Autologous Breast Reconstruction - Is It Safe and Reasonable?

Background

The use of autologous tissue for breast reconstructive surgery following mastectomy has become routine and allows for excellent symmetry and aesthetic results. However, in some cases, the amount of tissue available from the utilized flaps is not enough to achieve the desired outcome. The use of autologous fat grafting, as well as other techniques, has been described to deal with such problems. However, though well-established, these techniques may also fail to achieve the desired results. The aim of this study was to highlight the opportunity to improve aesthetic results using a secondary prosthesis underneath the previously used free flap and to examine whether this is a safe and reasonable procedure.

Material/Methods

In our study we included patients with unsatisfied aesthetic results after free flap procedures (DIEP, S-GAP, TMG, and FCI) between 2011 and 2018. In each case described, a secondary prosthesis was placed underneath the original flap in order to improve symmetry, shape and projection. Patient age, indication for surgery, adjuvant therapy, complications and outcomes have been registered. A 12-point scale was established to analyze patient satisfaction and aesthetic outcome.

Results

Overall “operative success” was achieved in all 13 patients (14 flaps) evaluated. At 12 months after reconstruction, all aesthetic scores collected were between good and excellent. In contrast to other studies, we chose a secondary approach for the flap augmentation and we used the epipectoral pocket for the placement of the implant. In our series, low rates of early and late post-operative complications were observed, with a high overall rate of satisfaction.

Conclusions

The demonstrated “Hybrid Breast Reconstruction” approach, using an implant underneath a free flap autologous breast reconstruction, provided a safe and reliable option to optimize breast reconstruction outcomes.

The Impact of Lidocaine on Adipose-Derived Stem Cells in Human Adipose Tissue Harvested by Liposuction and Used for Lipotransfer

The local anesthetic lidocaine, which has been used extensively during liposuction, has been reported to have cytotoxic effects and therefore would be unsuitable for use in autologous lipotransfer. We evaluated the effect of lidocaine on the distribution, number, and viability of adipose-derived stem cells (ASCs), preadipocytes, mature adipocytes, and leukocytes in the fatty and fluid portion of the lipoaspirate using antibody staining and flow cytometry analyses. Adipose tissue was harvested from 11 female patients who underwent liposuction. Abdominal subcutaneous fat tissue was infiltrated with tumescent local anesthesia, containing lidocaine on the left and lacking lidocaine on the right side of the abdomen, and harvested subsequently. Lidocaine had no influence on the relative distribution, cell number, or viability of ASCs, preadipocytes, mature adipocytes, or leukocytes in the stromal-vascular fraction. Assessing the fatty and fluid portions of the lipoaspirate, the fatty portions contained significantly more ASCs (p < 0.05), stem cells expressing the preadipocyte marker Pref-1 (p < 0.01 w/lidocaine, p < 0.05 w/o lidocaine), and mature adipocytes (p < 0.05 w/lidocaine, p < 0.01 w/o lidocaine) than the fluid portions. Only the fatty portion should be used for transplantation. This study found no evidence that would contraindicate the use of lidocaine in lipotransfer. Limitations of the study include the small sample size and the inclusion of only female patients.

Single Staged Mastopexy With Autologous Fat Grafting: An Alternative to Augmentation Mastopexy With Implants

BACKGROUND

Improving the ptotic breast with mastopexy and restoring upper pole fullness with augmentation continues to be a challenging issue for plastic surgeons. Autologous fat grating (AFG) for shaping and contouring of implant augmented breasts has shown positive outcomes with few complications.

OBJECTIVES

The objective of this study was to evaluate our experience with combined mastopexy and fat grafting for women with existing breast ptosis who prefer not to receive prosthetic breast implants but do desire volume enhancement.

METHODS

A retrospective review of patients undergoing a single staged mastopexy with AFG, from 2006 to 2017, was performed. Inclusion criteria were women with breast ptosis or tuberous breasts desiring improved breast shape and volume. Patients were excluded if they were undergoing implant removal before the procedure. Clinical aesthetic outcomes were assessed by fellow plastic surgeons according to the Telemark Breast Scoring system.

RESULTS

A total of 284 breasts, in 140 women, underwent a single staged mastopexy with AFG. The mean amount of fat grafted per breast was 299.4 mL (range, 50-710 mL). There were no surgical site infections, hematomas, or seromas. There were 3 major and 8 minor (0.06%) postoperative breast complications. A total of 13 plastic surgeons, of the 183 invited (7.1%), completed the breast outcomes survey. Regarding each category, there was significant improvement (P ≤ 0.0001) in upper pole fullness, ptosis, overall aesthetics, and symmetry postoperatively.

CONCLUSIONS

AFG combined with mastopexy is not associated with significant postoperative complications and results in excellent breast aesthetic outcomes.

LEVEL OF EVIDENCE: 4

Negative Pressure From an Internal Spiral Tissue Expander Generates New Subcutaneous Adipose Tissue in an In Vivo Animal Model

BACKGROUND

Tissue expanders are widely utilized in plastic surgery. Traditional expanders usually are "inflatable balloons," which are planned to grow additional skin and/or to create space to be filled, for example, with an implant. In very recent years, reports suggest that negative pressure created by an external device (ie, Brava) induces both skin expansion and adipogenesis.

OBJECTIVES

The authors evaluated and assessed the adipogenetic potential of a novel internal tissue expander in an in vivo animal model.

METHODS

New Zealand female rabbits were enrolled in the study. A prototype spiral inner tissue expander was employed. It consisted of a-dynamic conic expander (DCE) with a valve at the end: when empty, it is flat (Archimedean spiral), whereas when filled with a fluid, it takes a conic shape. Inside the conic spiral, a negative pressure is therefore created. DCE is implanted flat under the latissimus dorsi muscle in experimental animals (rabbit) and then filled to reach the conical shape. Animals were investigated with magnetic resonance imaging, histology, and transmission electronic microscopy at 3, 6, and 12 months.

RESULTS

Magnetic resonance imaging revealed a marked increase in newly formed adipose tissue, reaching its highest amount at 12 months after the DCE implantation. Histology confirmed the existence of new adipocytes, whereas transmission electronic microscopy ultrastructure confirmed that most of these new cells were mature adipocytes.

CONCLUSIONS

Tensile stress, associated with negative-pressure expanders, generated newly white subcutaneous adipose tissue.

Fat Grafting in Breast Reconstruction

The past two decades have witnessed a growing application of autologous fat grafting in the setting of breast reconstruction after surgical treatment of breast cancer. While traditionally used to correct contour deformities during secondary revisions, fat grafting has since evolved to achieve desired breast shape and size both as a complementary adjunct to established reconstructive techniques as well as a standalone technique for whole breast reconstruction. In this article, we will review fat grafting as an adjunct to autologous and implant-breast based reconstruction, an option for primary breast reconstruction, and a treatment of postmastectomy pain.

Efficacy of breast reconstruction with fat grafting: A systematic review and meta-analysis

BACKGROUND

Breast reconstruction with fat grafting is a new alternative to prosthetic implants and flaps for women with breast cancer. In this study, we investigate the efficacy of fat grafting for breast reconstruction in a meta-analysis.

METHODS

The study followed the PRISMA and MOOSE guidelines for systematic reviews and meta-analyses. Studies were included if the patients underwent complete breast reconstruction with fat grafting as the only treatment modality. The number of fat grafting treatments needed to complete a breast reconstruction was modeled in a meta-analysis for five treatment categories: modified radical mastectomy, skin-sparing mastectomy, and breast-conserving surgery; the two mastectomy groups were subdivided into nonirradiated and irradiated.

RESULTS

Twenty-one studies were included in the meta-analysis. The studies comprised 1011 breast reconstructions in 834 patients. The estimated numbers of treatments to complete a reconstruction were 2.84-4.66 in the mastectomy groups and 1.72 in the breast-conserving surgery group. The number of fat grafting sessions needed to complete a breast reconstruction was significantly higher for the irradiated patients than for the nonirradiated patients (p < 0.05). There was no significant difference in the number of fat grafting sessions needed to complete a breast reconstruction after a modified radical mastectomy versus a skin-sparing mastectomy.

CONCLUSIONS

This study provides an evidence-based foundation for several practical issues related to breast reconstruction with fat grafting. The analysis showed that radiotherapy is the most important factor associated with the number of treatment sessions needed to complete a breast reconstruction and with the rate of complications.