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

Breast reconstruction after mastectomy

Patients requesting breast reconstruction after mastectomy is an increasing group at plastic- and breast surgery departments in Denmark. This review summarises the present surgical techniques for reconstruction with/without postoperative chemotherapy and/or radiation therapy. These surgical techniques are continuously updated. The most determining factor when selecting a reconstructive technique, is postoperative radiation therapy. Each patient is unique, and an individual assessment is made when planning surgery. The concept of a "babysitter implant" is currently being investigated in Denmark and might be an option for selected patients.

Current trends in postmastectomy breast reconstruction

PURPOSE OF REVIEW

Breast reconstruction is established as integral part of the treatment. New materials, indications and surgical techniques are subject to rapid modification to further improve safety, quality and longevity.

RECENT FINDINGS

Skin-sparing-mastectomy is accepted as an appropriate alternative in risk-reducing and many breast cancer patients, further reducing conventional mastectomy patterns.Radiation in combination with reconstruction is still challenging with no clear advances reducing skin-toxicity.Autologous reconstructions, not only in radiation settings, are turning to a first line approach. A trend driven by improved techniques to minimize morbidity and flap-variations.Breast implant surfaces associated with a high risk of Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) are now withdrawn. The residual risk for the remaining implant styles is not known, but can be expected considerably lower than estimations published presently.In order to reduce local complications, supplemental material often in combination with prepectoral implant placement is advertised. The present evidence on long-term outcome is limited.Super-microsurgery treating lymphedema is evolving rapidly. Refinements of various techniques and their differential indication are under evaluation to standardize the procedures.

SUMMARY

Breast reconstruction evolved to a complex, specialized field with a multitude of options. A multidisciplinary team is required to fully utilize todays potential and offer optimal individual treatments.

Meta-Analysis of the Oncological Safety of Autologous Fat Grafting After Breast Cancer on Basic Science and Clinical Studies

BACKGROUND

The purpose of the present study was to comprehensively evaluate the oncological safety of autologous fat grafting after breast cancer by combining experimental and clinical studies.

METHODS

All studies published before August 2021 were collected by searching PubMed, Cochrane, Embase, Web of Science, SINOMED, and China National Knowledge Infrastructure. After screening the research and extracting the data, RevMan was used to perform the meta-analysis.

RESULTS

Five basic science studies and 26 clinical studies, involving a total of 10,125 patients, were eventually included. In the basic science studies, adipose-derived stem cells promoted breast cancer growth, but fat grafting and adipose-derived stem cells plus fat grafting were not associated with breast cancer growth. An overall analysis of clinical studies showed that autologous fat grafting does not increase the risk of breast cancer recurrence. Subgroup analyses indicated that autologous fat grafting did not increase the risk of breast cancer recurrence in Asian or Caucasian patients, in patients undergoing breast-conserving surgery or modified radical mastectomy, in patients with in situ carcinomas or invasive carcinomas, or in patients undergoing postoperative radiotherapy.

CONCLUSION

This study combined experimental and clinical studies to conclude that autologous fat grafting does not increase the risk of breast cancer recurrence. However, the experimental results suggest that adipose-derived stem cells should be used with caution after breast cancer surgery.

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 .

The oncological safety of autologous fat grafting: a systematic review and meta-analysis

Objective

To present a systematic review of the literature and a meta-analysis evaluating the oncological safety of autologous fat grafting (AFG).

Summary background data: AFG for breast reconstruction presents difficulties during follow-up radiological exams, and the oncological potential of grafted fat is uncertain. Previous studies confirmed that the fatty tissue could be transferred under a good condition suitable would not interfere with mammographic follow-up, although the issue of oncological safety remains.

Methods

We reviewed the literature published until 01/18/2021. The outcomes were overall survival (OS), disease-free survival (DFS), and local recurrence (LR). We included studies that evaluated women with breast cancer who undergone surgery followed by reconstruction with AFG. We synthesized data using the inverse variance method on the log-HR (log of the hazard ratio) scale for time-to-event outcomes using RevMan. We assessed heterogeneity using the Chi² and I² statistics.

Results

Fifteen studies evaluating 8541 participants were included. The hazard ratios (HR) could be extracted from four studies, and there was no difference in OS between the AFG group and control (HR 0.9, 95% CI 0.53 to 1.54, p = 0.71, I² = 58%, moderate certainty evidence), and publication bias was not detected. The HR for DFS could be extracted from six studies, and there was no difference between the AFG group and control (HR 1.01, 95% CI 0.73 to 1.38, p = 0.96, I² = 0%, moderate certainty evidence). The HR for LR could be extracted from ten studies, and there was no difference between the AFG group and control (HR 0.86, 95% CI 0.66 to 1.12, p = 0.43, I² = 1%, moderate certainty evidence).

Conclusion

According to the current evidence, AFG is a safe technique of breast reconstruction for patients that have undergone BC surgery and did not affect OS, DFS, or LR.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-022-09485-5.

Fat Grafting following Internal Tissue Expansion: An Option for Breast Reconstruction after Total Mastectomy

Background:

Breast reconstruction is currently performed as standard practice.

Methods:

A prospective study was performed of patients after total mastectomy who underwent autologous breast reconstruction with fat grafting (FG) combined with internal tissue expansion between September 2015 and December 2020. The patients were classified into groups A to F depending on the steps of breast reconstruction. Groups A and B described patients with completed breast reconstruction with FG and expander removal, with or without nipple/areola complex reconstruction. C described patients during deflation of the expander combined with simultaneous FG. D described patients after expander implantation and refilling. E described patients after first FG, and F included patients who discontinued reconstruction with the described method and converted to reconstruction with a breast implant.

Results:

Among 22 treated patients‚ two were after first FG (9.09%‚ group E), two were after expander implantation and refilling (9.09%‚ group D), three were during deflation of the expander combined with simultaneous FG (13.63%‚ group C), and four (18.18%) had completed breast reconstruction—two (9.09%) without NAC reconstruction and symmetrization (group B) and two (9.09%) with completed breast reconstruction (group A). In 11 patients (50%), breast reconstruction was abandoned after expander implantation and one to three FG procedures (group F), converting to breast reconstruction with a breast implant.

Conclusions:

This study demonstrated successful breast reconstruction using FG and expander implantation. Breast reconstruction using this method is safe and enables possible abandonment at any treatment stage, as well as conversion to breast reconstruction with implants.

Breast Reconstruction: Necessity for Further Standardization of the Current Surgical Techniques Attempting to Facilitate Scientific Evaluation and Select Tailored Individualized Procedures Optimizing Patient Satisfaction

Background

Various breast cancer reconstruction methods and novel surgical techniques include autologous or allogenic procedures, which can increase patient's quality of life and provide options when dealing with patients seen as challenging clinical scenarios.

Summary

Our aim was to review the current literature and present published evidence on innovative standards in whole breast reconstruction. Advances in flap monitoring or newly published data regarding neurotization in breast reconstruction, arm lymphedema management, breast implant-associated anaplastic large cell lymphoma reconstruction treatment, and robotic surgery with regard to radiotherapy define innovative standards in the breast reconstruction setting. The role of meshes/acellular dermal matrix and fat grafting as well as optimal sequencing of postmastectomy radiotherapy in autologous and alloplastic breast reconstruction appear highly debatable also in expert panel meetings rendering further clinical research including RCTs imperative.

Key Messages

There is an abundance of novel available techniques, which mandate further standardization, facilitating scientific evaluation in an attempt to help surgeons select tailored procedures for each patient with the goal to promote informed decision-making in breast reconstruction.