Autologous Fat Grafting After Breast Reconstruction in Postmastectomy Patients: Complications, Biopsy Rates, and Locoregional Cancer Recurrence Rates

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.

The Evolving Function of Vasculature and Pro-angiogenic Therapy in Fat Grafting

Autologous fat grating is a widely-accepted method to correct soft tissue deficiency. Although fat transplantation shows excellent biocompatibility and simple applicability, the relatively low retention rate caused by fat necrosis is still a challenge. The vasculature is integral after fat grafting, serving multiple crucial functions. Rapid and effective angiogenesis within grafts is essential for supplying oxygen necessary for adipocytes' survival. It facilitates the influx of inflammatory cells to remove necrotic adipocytes and aids in the delivery of regenerative cells for adipose tissue regeneration in fat grafts. The vasculature also provides a niche for interaction between adipose progenitor cells and vascular progenitor cells, enhancing angiogenesis and adipogenesis in grafts. Various methods, such as enriching grafts with diverse pro-angiogenic cells or utilizing cell-free approaches, have been employed to enhance angiogenesis. Beige and dedifferentiated adipocytes in grafts could increase vessel density. This review aims to outline the function of vasculature in fat grafting and discuss different cell or cell-free approaches that can enhance angiogenesis following fat grafting.

[Update and Trends in Breast Reconstruction After Mastectomy]

Due to refinements in operating techniques, autologous breast reconstruction has become part of standard care. It has become more difficult to advise patients due to the expansion of oncologic options for mastectomy, radiation therapy and the variety of reconstructive techniques. The goal of reconstruction is to achieve oncologically clear margins and a long-term aesthetically satisfactory result with a high quality of life. Immediate reconstruction preserves the skin of the breast and its natural form and prevents the psychological trauma associated with mastectomy. However, secondary reconstructions often have a higher satisfaction, since here no restitutio ad integrum is assumed. Alloplastic, i. e., implant-based, breast reconstruction and autologous breast reconstruction are complementary techniques. This article provides an overview of current options for breast reconstruction including patients' satisfaction and quality of life following breast reconstruction. Although immediate reconstruction is still the preferred choice of most patients and surgeons, delayed reconstruction does not appear to compromise clinical or patient-reported outcomes. Recent refinements in surgical techniques and autologous breast reconstruction include stacked-flaps, as well as microsurgical nerve coaptation to restore sensitivity, which lead to improved outcomes and quality of life. Nowadays Skin-sparing and nipple-sparing mastectomy, accompanied by improved implant quality, allows immediate prosthetic breast reconstruction as well as reemergence of the prepectoral implantation. The choice of breast reconstruction depends on the type of mastectomy, necessary radiation, individual risk factors, as well as the patient's habitus and wishes. Overall, recent developments in breast reconstruction led to an increase in patient satisfaction, quality of life and aesthetic outcome with oncological safety.

BREAST-Q Patient-reported Outcomes in Different Types of Breast Reconstruction after Fat Grafting

Breast reconstruction after mastectomy improves patient quality of life. Independently of the type of reconstruction, ancillary procedures are sometimes necessary to improve results. Fat grafting to the breast is a safe procedure with excellent results. We report patient-reported outcomes using the BREAST-Q questionnaire after autologous fat grafting in different types of reconstructed breasts.

Methods

We performed a single-center, prospective, comparative study that compared patient-reported outcomes using the BREAST-Q in patients after different types of breast reconstruction (autologous, alloplastic, or after breast conserving) who subsequently had fat grafting.

Results

In total, 254 patients were eligible for the study, but only 54 (68 breasts) completed all the stages needed for inclusion. Patient demographic and breast characteristics are described. Median age was 52 years. The mean body mass index was 26.1 ± 3.9. The mean postoperative period at the administration of BREAST-Q questionnaires was 17.6 months. The mean preoperative BREAST-Q was 59.92 ± 17.37, and the mean postoperative score was 74.84 ± 12.48 (P < 0.0001). There was no significant difference when divided by the type of reconstruction.

Conclusion

Fat grafting is an ancillary procedure that improves the outcomes in breast reconstruction independently of the reconstruction type and heightens patient satisfaction, and it should be considered an integral part of any reconstruction algorithm.

Postoperative Antibiotics Confer No Protective Association After Fat Grafting for Breast Reconstruction

INTRODUCTION

Autologous fat grafting after breast reconstruction is a commonly used technique to address asymmetry and irregularities in breast contour. While many studies have attempted to optimize patient outcomes after fat grafting, a key postoperative protocol that lacks consensus is the optimal use of perioperative and postoperative antibiotics. Reports suggest that complication rates for fat grafting are low relative to rates after reconstruction and have been shown to not be correlated to antibiotic protocol. Studies have additionally demonstrated that the use of prolonged prophylactic antibiotics do not lower the complication rates, stressing the need for a more conservative, standardized antibiotic protocol. This study aims to identify the optimal use of perioperative and postoperative antibiotics that optimizes patient outcomes.

METHODS

Patients in the Optum Clinformatics Data Mart who underwent all billable forms of breast reconstruction followed by fat grafting were identified via Current Procedural Terminology codes. Patients meeting inclusion criteria had an index reconstructive procedure at least 90 days before fat grafting. Data concerning these patient's demographics, comorbidities, breast reconstructions, perioperative and postoperative antibiotics, and outcomes were collected via querying relevant reports of Current Procedural Terminology; International Classification of Diseases, Ninth Revision; International Classification of Diseases, Tenth Revision; National Drug Code Directory, and Healthcare Common Procedure Coding System codes. Antibiotics were classified by type and temporal delivery: perioperatively or postoperatively. If a patient received postoperative antibiotics, the duration of antibiotic exposure was recorded. Outcomes analysis was limited to the 90-day postoperative period. Multivariable logistic regression was performed to ascertain the effects of age, coexisting conditions, reconstruction type (autologous or implant-based), perioperative antibiotic class, postoperative antibiotic class, and postoperative antibiotic duration on the likelihood of any common postoperative complication occurring. All statistical assumptions made by logistic regression were met successfully. Odds ratios and corresponding 95% confidence intervals were calculated.

RESULTS

From more than 86 million longitudinal patient records between March 2004 and June 2019, our study population included 7456 unique records of reconstruction-fat grafting pairs, with 4661 of those pairs receiving some form of prophylactic antibiotics. Age, prior radiation, and perioperative antibiotic administration were consistent independent predictors of increased all-cause complication likelihood. However, administration of perioperative antibiotics approached a statistically significant protective association against infection likelihood. No postoperative antibiotics of any duration or class conferred a protective association against infections or all-cause complications.

CONCLUSIONS

This study provides national, claims-level support for antibiotic stewardship during and after fat grafting procedures. Postoperative antibiotics did not confer a protective benefit association against infection or all-cause complication likelihood, while administering perioperative antibiotics conferred a statistically significant increase in the likelihood that a patient experienced postoperative complication. However, perioperative antibiotics approach a significant protective association against postoperative infection likelihood, in line with current guidelines for infection prevention. These findings may encourage the adoption of more conservative postoperative prescription practices for clinicians who perform breast reconstruction, followed by fat grafting, reducing the nonindicated use of antibiotics.

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.

A Preliminary Exploratory Study of Autologous Fat Transplantation in Breast Augmentation With Different Fat Transplantation Planes

Background

Autologous fat transfer is common in breast augmentationor reconstruction. However, AFG recipient site in the breast for fat grafting has not been carefully investigated.

Methods

Forty female patients requiring breast augmentation with fat grafting were randomly assigned into two groups. The retromammary group received 2/3 fat into the retromammary space and the other 1/3 into the subcutaneous and retropectoral planes. The retropectoral group received 2/3 fat into the retropectoral plane and the other 1/3 into the subcutaneous and retromammary planes. The fat grafting result at 6 months was assessed by 3D laser surface scanning and then ultrasound. Any complications were recorded during follow-up. Samples from a patient who underwent fat grafting for 6 months was obtained and histological examination was conducted.

Results

No significant difference in the retention rate after 6 months was observed between the two groups (retromammary group: 35.9% ± 6.6; retropectoral group: 39.3% ± 5.1, p = 0.1076). The retromammary grouphad a higher incidence of oil cyst formation than the retropectoral group. Histological examination showed that there were more oil cysts and mac2 positive macrophage infiltration in the fat cells in retromammary group, while retropectoral group had more small-size adipocytes.

Conclusion

Although fat grafting into the retropectoral plane did not provide a superior fat graft retention rate, it did lower the incidence of complications. The retropectoral space show great potential to become a favorable recipient site.

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 .

The use of Liposuction to treat significant contour abnormalities associated with Lipomyeloeningocoele

INTRODUCTION

Since 1972 when first pioneered, liposuction has developed and is now one of the commonest aesthetic procedures performed worldwide. Evidence of its application in aesthetic lipomodelling is widely known, but there are scant reports in the literature on the use of liposuction in more unusual cases. We report its use as a safe and successful method of contour correction in two cases of lipomyelomeningocoele (LMMC), a form of spina bifida. To our knowledge, this has never been reported before.

METHOD

A prospective review was performed and both cases were followed up during the treatment period. Both patients were treated at the Royal Belfast Hospital for Sick Children. Patient charts were reviewed and magnetic resonance imaging was used.

RESULTS

Two patients, aged 11 and 17 years, had a large LMMC over the lumbosacral area. Preoperative imaging was obtained in each case to ensure the procedure could safely avoid the underlying spinal cord structures. The use of the Microaire© suction device allowed precise fat extraction. Postoperative images demonstrate reduction of lipomatous bulk and improved contour.

CONCLUSION

We have shown that when used with caution liposuction is a safe and effective technique for volume reduction of a LMMC in carefully selected cases.

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.

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.

Evaluation of Postoperative Repair Effect of Oral Tumors Based on Free Ultrasound Flap Transplantation

In this paper, the treatment of oral tumors with free flap transplantation based on ultrasound contrast is studied, and the repair effect is analyzed and evaluated in-depth, the postoperative quality of life of patients with oral malignant tumors is evaluated, and the factors affecting their quality of life are analyzed. 120 patients with oral malignant tumors were selected. The continuity of the jaws, neck clearance method, clinical stage, tumor recurrence, radiotherapy, and chemotherapy all have varying degrees of impact on the postoperative quality of life. Multivariate analysis suggests that tumor recurrence has the greatest impact on the quality of life of patients followed by jaw continuity, tumor stage, with or without neck clearance. First, the early detection rate of tumors should be improved, and the tumors should be removed as completely as possible during the operation to avoid residues. If necessary, cervical lymph node dissection can be performed. Patients with discontinuous jaws should be reconstructed and repaired in time to restore the maxillofacial shape and function of the patients, to greatly reduce the impact on the quality of life of patients after surgery.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Post-mastectomy Breast Reconstruction with Autologous Tissue: Current Methods and Techniques

Breast reconstruction is an option that should be considered for any patient facing a mastectomy. Autologous breast reconstruction provides the benefits of excellent longterm results, natural appearance, natural feel, and the best opportunity for sensory restoration. These factors lead many patients to choose autologous tissue over implant-based reconstruction. With improved anatomic and technical knowledge, the donor site morbidity previously associated with abdominally based autologous reconstruction has been significantly reduced. Today, the DIEP flap is the preferred autologous method allowing restoration of a “natural,” aesthetic breast with potential for sensation while simultaneously minimizing abdominal donor site morbidity. Alternative flaps and adjunctive procedures provide options when dealing with patients who present with challenging clinical scenarios because of an inadequate abdominal donor site. This paper reviews current methods employed by a high volume breast reconstruction practice to achieve these goals.

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

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

The Influence of Fat Grafting on Breast Imaging after Postmastectomy Reconstruction: A Matched Cohort Analysis

BACKGROUND

Fat grafting to the reconstructed breast may result in the development of benign lesions on physical examination, prompting further investigation with imaging and biopsy. The aim of this study was to assess the influence of fat grafting on the incidence of imaging and biopsies after postmastectomy reconstruction.

METHODS

Patients who underwent autologous or implant-based reconstruction following mastectomy from 2010 to 2018 were identified. Those receiving fat grafting as part of their reconstructive course were propensity matched 1:1 to those that did not with body mass index, reconstruction timing, and reconstruction type as covariates in a multivariable logistic regression model.

RESULTS

A total of 186 patients were identified, yielding 93 propensity-matched pairs. Fat-grafted patients had higher incidences of palpable masses (38.0 percent versus 18.3 percent; p = 0.003) and postreconstruction imaging (47.3 percent versus 29.0 percent; p = 0.01), but no significant difference in the number of biopsies performed (11.8 percent versus 7.5 percent; p = 0.32). Imaging was predominately interpreted as normal (Breast Imaging-Reporting and Data System 1, 27.9 percent) or benign (Breast Imaging-Reporting and Data System 2, 48.8 percent), with fat necrosis being the most common finding [n = 20 (45.5 percent)]. No demographic, oncologic, reconstructive, or fat grafting-specific variables were predictive of receiving postreconstruction imaging on multivariate analysis. Fat grafting was not associated with decreased 5-year overall survival or locoregional recurrence-free survival.

CONCLUSIONS

Fat grafting to the reconstructed breast is associated with increased incidences of palpable masses and subsequent postreconstruction imaging with benign radiographic findings. Although the procedure is oncologically safe, both patients and providers should be aware that concerning physical examination findings can be benign sequelae of fat grafting and may lead to increased imaging after breast reconstruction.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

ACR Appropriateness Criteria® Imaging After Mastectomy and Breast Reconstruction

Mastectomy may be performed to treat breast cancer or as a prophylactic approach in women with a high risk of developing breast cancer. In addition, mastectomies may be performed with or without reconstruction. Reconstruction approaches differ and may be autologous, involving a transfer of tissue (skin, subcutaneous fat, and muscle) from other parts of the body to the chest wall. Reconstruction may also involve implants. Implant reconstruction may occur as a single procedure or as multistep procedures with initial use of an adjustable tissue expander allowing the mastectomy tissues to be stretched without compromising blood supply. Ultimately, a full-volume implant will be placed. Reconstructions with a combination of autologous and implant reconstruction may also be performed. Other techniques such as autologous fat grafting may be used to refine both implant and flap-based reconstruction. This review of imaging in the setting of mastectomy with or without reconstruction summarizes the literature and makes recommendations based on available evidence. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Surgical Management of the Explant Patient: An Update on Options for Breast Contouring and Volume Restoration

BACKGROUND

Breast implant removal is becoming a common procedure in light of the current events and controversies with silicone breast implants. The authors believe strongly in informing patients about the indications and options regarding both explantation and the management of the secondary breast deformity.

METHODS

Relevant literature regarding the management of the explant patient was reviewed and organized to provide an update on prior publications addressing the explant patient population.

RESULTS

Surgical management options after implant removal include breast contouring and volume restoration. Fat augmentation has been used in both aesthetic and reconstructive breast surgery.

CONCLUSIONS

The authors review the surgical management for explantation, breast contouring, and autologous fat grafting for volume restoration. In the explant patient, autologous fat grafting serves as a reliable option for volume restoration.

Comparison of Telfa Rolling and a Closed Washing System for Autologous Fat Processing Techniques in Postmastectomy Breast Reconstruction

BACKGROUND

The purpose of this study was to compare the commonly used fat grafting techniques-Telfa rolling and a closed washing system-in breast reconstruction patients.

METHODS

Consecutive patients undergoing fat grafting were retrospectively reviewed and grouped by technique. Patients with less than 180 days of follow-up were excluded. Demographics, operative details, and complications were compared using univariate analysis with significance set at p < 0.05.

RESULTS

Between January of 2013 and September of 2017, 186 women underwent a total of 319 fat grafting procedures. There was no difference in demographics, number of procedures performed, volume of fat grafted, and number of days after reconstruction that fat grafting was performed between groups (p > 0.05). Telfa rolling patients had longer operative times for second fat grafting procedures (implant exchange often completed prior) [100.0 minutes (range, 60.0 to 150.0 minutes) versus 79.0 minutes (range, 64.0 to 94.0 minutes); p = 0.03]. Telfa rolling breasts had more palpable masses requiring imaging (26.0 percent versus 14.4 percent; p = 0.01) and an increased incidence of fat necrosis (20.6 percent versus 8.0 percent; p < 0.01). The closed washing system was found to be an independent predictor of decreased rates of imaging-confirmed fat necrosis (OR, 0.29; p = 0.048). There was no difference in fat necrosis excision or cancer recurrence between the groups.

CONCLUSION

The closed washing system was independently associated with decreased rates of imaging-confirmed fat necrosis compared to Telfa rolling without an increase in other complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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.

A Comparison of Fat Graft Processing Techniques: Outcomes in 1,158 Procedures in Prosthetic Breast Reconstructions

As fat grafting in breast reconstruction evolves, questions of technique and outcomes persist. We compared 2 common fat processing techniques—decantation (DEC) versus closed wash and filtration (CWF)—with regard to outcomes and efficacy.

Fat Grafting and the Palpable Breast Mass in Implant-Based Breast Reconstruction: Incidence and Implications

BACKGROUND

Fat grafting is a powerful and increasingly used technique in breast reconstruction. However, fat necrosis can lead to palpable postoperative changes that can induce anxiety and lead to unplanned diagnostic studies. The authors' aim in this study was to evaluate the incidence, type, and timing of these unanticipated studies; the specialty of the ordering provider; and the factors that trigger the ordering process.

METHODS

A retrospective chart review was conducted for patients from 2006 to 2015 who underwent fat grafting as part of implant-based breast cancer reconstruction and had at least 1-year follow-up after fat grafting.

RESULTS

From 2006 to 2015, 166 patients underwent fat grafting as part of implant-based breast reconstruction. Forty-four women (26.5 percent) underwent at least one imaging procedure. Thirteen women (7.8 percent) underwent 17 biopsies. For a palpable mass, the initial imaging test most commonly ordered was ultrasound, followed by mammography/ultrasound. The percentage of patients with a diagnosis of fat necrosis on mammography, ultrasound, and biopsy was 4.2, 12.7, and 5.4 percent, respectively. Seven patients (4.2 percent) had distant metastases. Tissue diagnosis of local recurrence was never identified. Mean follow-up was 2.4 years.

CONCLUSIONS

Fat-grafting sequelae may lead to early unplanned invasive and noninvasive procedures initiated by a variety of providers. In this study, fat grafting had no impact on local recurrence rate. As use of fat grafting grows, communication among breast cancer care providers and enhanced patient and caregiver education will be increasingly important in optimizing the multidisciplinary evaluation and monitoring of palpable breast lesions.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

International Expert Panel Consensus on Fat Grafting of the Breast

Background

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

Methods

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

Results

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

Conclusions

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

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 Grafting for Craniofacial Reconstruction in Oncologic Patients

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

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.

Unusual recurrence of breast cancer in a BRCA-variant patient after fat grafting

The oncologic safety of fat grafting procedures remains well-characterized in the recent literature; however, we recommend exercising vigilance when evaluating BRCA-positive and other patients at higher oncologic risk after reconstruction and fat grafting, whose cancer recurrence diagnosis may pose significant clinical challenges.

The Pyramidal Flap: an Innovative Technique for DIEP Flap Refinement

Supplemental Digital Content is available in the text.

DIEP flap is considered the gold standard technique for breast reconstruction. One of the most frequent contour deformities after breast reconstruction with DIEP flap is a step-off deformity at the interface between the native chest wall and the reconstructed breast. Different techniques have been used to address this problem. We describe the pyramidal flap as a simple, single stage and low risk procedure, which specifically corrects the step-off or tapering deformity of the reconstructed breast with DIEP flap.

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

Lipofilling ok

Non-Tuberculous Mycobacteria Infection Following Autologous Fat Grafting on the Face

LEVEL OF EVIDENCE

5.

Association of Fat Grafting With Patient-Reported Outcomes in Postmastectomy Breast Reconstruction

Importance

Fat grafting has proven to be a useful adjunct to breast reconstruction for the treatment of contour irregularities and volume deficits, but the proposed US Food and Drug Administration regulations may severely limit the ability of plastic surgeons to continue its use in this clinical context.

Objective

To determine whether fat grafting is associated with patient-reported outcomes (PROs) in patients undergoing breast reconstruction.

Design, Setting, and Participants

A longitudinal, multicenter, prospective cohort study was conducted between February 1, 2012, and July 31, 2016, at the 11 sites associated with the Mastectomy Reconstruction Outcomes Consortium Study. Eligible patients included women 18 years or older presenting for breast reconstruction after mastectomy with 2 years or more of follow-up. All primary procedure types (implant based and flap based) were eligible. Patients were excluded if they had not completed breast mound reconstruction by 1 year after starting reconstruction.

Interventions

Fat grafting as an adjunct to breast mound reconstruction.

Main Outcomes and Measures

Primary end points were patient-reported outcome measures as assessed by the validated BREAST-Q survey, with higher scores on a 0- to 100-point scale indicating better health-related quality of life. Survey subscales included breast satisfaction, as well as psychosocial, physical, and sexual well-being. Patient-reported outcomes were compared between those who received and did not receive fat grafting.

Results

A total of 2048 women were included (mean [SD] age, 49.4 [10] years), with 165 (8.1%) undergoing fat grafting between years 1 and 2. One year postoperatively, patients who later underwent fat grafting reported significantly lower breast satisfaction (adjusted mean difference [AMD], -4.74; 95% CI, -8.21 to -1.28; P = .008), psychosocial well-being (AMD, -3.87; 95% CI, -7.33 to -0.40; P = .03), and sexual well-being (AMD, -5.59; 95% CI, -9.70 to -1.47; P = .008), compared with those who did not receive subsequent fat grafting. Following the procedure, the fat-grafted cohort reported similar breast satisfaction (AMD, -0.68; 95% CI, -4.42 to 3.06; P = .72), psychosocial well-being (AMD, -0.59; 95% CI, -3.92 to 2.74; P = .73), and sexual well-being (AMD, -2.94; 95% CI, -7.01 to 1.12; P = .15) 2 years postoperatively.

Conclusions and Relevance

Fat grafting may improve breast satisfaction, psychosocial well-being, and sexual well-being in patients undergoing breast reconstruction.

Assessment of the clinical efficacy of cell-assisted lipotransfer and conventional fat graft: a meta-analysis based on case-control studies

Background

Cell-assisted lipotransfer is a novel technique for fat grafting. This study aimed to investigate the clinical efficacy of cell-assisted lipotransfer technology compared with conventional fat grafting.

Methods

According to PRISMA guidelines, related articles in PubMed, Embase and Cochrane library were systematically searched. Studies focusing on fat survival rate and/or patient satisfaction rate for fat grafting alone versus cell-assisted lipotransfer were retrieved. Estimated fat survival and patient satisfaction rates were pooled. Subgroup analysis was stratified by the transplant site. Publication bias was conducted. Furthermore, the stability of results was assessed by sensitivity analysis.

Results

Nine articles were included in the meta-analysis. Significant heterogeneity was observed among individual studies for fat survival rate assessment (I² = 98.3%, P < 0.001). The fat survival rate was significantly higher in the cell-assisted lipotransfer group than in the control group [weighted mean difference = 25.85, 95% confidence interval 5.39–46.31; P = 0.013]. Notably, results remained unchanged in the sensitivity analyses. No significant difference was found in the patient satisfaction rate between the cell-assisted lipotransfer and control groups [odds ratio = 3.69, 95% confidence interval 0.73–18.53; P = 0.113]. In subgroup analysis, a significantly higher patient satisfaction rate was found in cell-assisted lipotransfer fat graft group in the face (odds ratio = 18.85, 95% confidence interval 9.03, 28.68; P < 0.001) and arm (odds ratio = 64.60, 95% confidence interval 58.79, 70.41; P < 0.001) than in the controls. Finally, no significant publication bias was found (P = 0.371).

Conclusion

This study suggests that cell-assisted lipotransfer is superior to conventional lipoinjection with improved fat survival rate. However, the long-term efficacy should be evaluated in further studies.

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

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

Comparison of two different types of oxidized regenerated cellulose for partial breast defects

BACKGROUND

A defect after partial mastectomy, sometimes, is hard to be filled with patient's own breast tissue. Two different types of oxidized regenerated cellulose (ORC) for filling of partial defects in small-sized breasts were compared with respect to clinicopathologic factors and outcomes.

METHODS

A total of 45 patients with breast cancer underwent conventional partial mastectomy with insertion of an ORC filling material. The two filling materials used were a hemostasis-purposed ORC and adhesion barrier-purposed ORC. Clinical factors were compared between these two ORC materials. Both the surgeon and patient assessed the cosmetic outcomes using the Harvard/NSABP/RTOG Breast Cosmesis Grading Scale.

RESULTS

Partial mastectomy with filling material insertion technique was not inferior to partial mastectomy-only technique in many clinical aspects. And most of the clinicopathologic factors showed no significant difference between the two groups. However, the mean operation time was significantly shorter in the hemostasis-purposed ORC group (P = 0.027). In addition, the infection rate was significantly higher in the adhesion barrier-purposed ORC group (P = 0.040).

CONCLUSIONS

Reconstructive surgery using a hemostasis-purposed ORC was associated with a shorter operation time and lower incidence of postoperative infection than that using an adhesion barrier-purposed ORC. However, both types of ORC were feasible as filling compounds for partial defects of the breast.

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

OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

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

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

Breast Reconstruction after Mastectomy

Breast cancer is the leading cause of cancer death in women worldwide. Its surgical approach has become less and less mutilating in the last decades. However, the overall number of breast reconstructions has significantly increased lately. Nowadays, breast reconstruction should be individualized at its best, first of all taking into consideration not only the oncological aspects of the tumor, neo-/adjuvant treatment, and genetic predisposition, but also its timing (immediate versus delayed breast reconstruction), as well as the patient's condition and wish. This article gives an overview over the various possibilities of breast reconstruction, including implant- and expander-based reconstruction, flap-based reconstruction (vascularized autologous tissue), the combination of implant and flap, reconstruction using non-vascularized autologous fat, as well as refinement surgery after breast reconstruction.