Lipotransfer Strategies and Techniques to Achieve Successful Breast Reconstruction in the Radiated Breast

A Novel Fat-Augmented Omentum-Based Construct for Unilateral and Bilateral Free-Flap Breast Reconstruction in Underweight and Normal Weight Women Receiving Nipple or Skin-Sparing Mastectomies

BACKGROUND

Autologous tissue has proven advantages, however it is often not an option for women of low or normal body mass index (BMI). Omentum has been used sparingly, typically as a pedicled flap to correct breast deformities, but is considered suboptimal for full breast reconstruction. We developed a new construct, the omental fat-augmented free flap (O-FAFF) as an alternative for breast reconstruction.

METHODS

O-FAFF involves laparoscopic omentum harvesting, creation of an acellular dermal matrix shell for its encasement, and lipoinjection to augment volume. The gastroepiploic vessels are microsurgically anastomosed to internal mammary vessels. Tissue and O-FAFF construct weights as well as outcomes are reported.

RESULTS

Thirty-four consecutive women (50 breasts) received O-FAFF breast reconstruction after 18 unilateral and 16 bilateral mastectomies (10 non-nipple-sparing, 40 nipple-sparing). Thirty-seven were immediate and 13 were revisions of previous breast reconstructions. Patient mean age was 48.2 (range 23-73) years and mean BMI was 22.3 (range 17.6-32.4) kg/m². Mean follow-up was 14.8 (range 3-33) months. The median weight of the omentum was 161.7 g (range 81-852, interquartile range [IQR] 102) and the mean ratio of fat to omentum weight was 0.73 (range 0.22-1.38) and 1.97 (range 0.24-3.8) for unilateral and bilateral cases, respectively. Postoperative pain scores and oral morphine equivalent consumption were more favorable for the O-FAFF group compared with controls (p < 0.001). Follow-up breast MRI demonstrated intact perfusion and no fat necrosis.

CONCLUSIONS

The O-FAFF is ideally suited for women of lower BMI and could dramatically increase the number of women who are candidates for autologous breast reconstruction.

Outcomes in Hybrid Breast Reconstruction: A Systematic Review

Background and Objectives: Lipofilling is a commonly performed procedure worldwide for breast augmentation and correction of breast contour deformities. In breast reconstruction, fat grafting has been used as a single reconstructive technique, as well as in combination with other procedures. The aim of the present study is to systematically review available studies in the literature describing the combination of implant-based breast reconstruction and fat grafting, focusing on safety, complications rate, surgical sessions needed to reach a satisfying reconstruction, and patient-reported outcomes. Materials and Methods: We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) throughout the whole review protocol. A systematic review of the literature up to April 2022 was performed using Medline, Embase, and Cochrane Library databases. Only studies dealing with implant-based breast reconstruction combined with fat grafting were included. Results: We screened 292 articles by title and abstract. Only 48 articles were assessed for full-text eligibility, and among those, 12 studies were eventually selected. We included a total of 753 breast reconstructions in 585 patients undergoing mastectomy or demolitive breast surgeries other than mastectomy (quadrantectomy, segmentectomy, or lumpectomy) due to breast cancer or genetic predisposition to breast cancer. Overall, the number of complications was 60 (7.9%). The mean volume of fat grafting per breast per session ranged from 59 to 313 mL. The mean number of lipofilling sessions per breast ranged from 1.3 to 3.2. Conclusions: Hybrid breast reconstruction shows similar short-term complications to standard implant-based reconstruction but with the potential to significantly decrease the risk of long-term complications. Moreover, patient satisfaction was achieved with a reasonably low number of lipofilling sessions (1.7 on average).

The Effect of Fat Grafting on Expansion Pressures in Expander-Based Postmastectomy Breast Reconstruction: Outcomes in Normal and Irradiated Tissues

INTRODUCTION

The impact of fat grafting on the viscoelasticity of irradiated tissues is poorly defined. We investigate the effect of subcutaneous fat grafting on postmastectomy tissue expansion in patients undergoing delayed breast reconstruction. We quantify observed viscoelastic and trophic changes of the skin envelope. We hypothesize that fat grafting changes the trophic and viscoelastic properties of the breast soft tissue envelope.

METHODS

Postmastectomy defects delayed more than 2 years and reconstructed with subpectoral tissue expanders were prospectively studied. Control (no irradiation, no fat grafting, n = 7), fat grafted (no irradiation, fat grafting n = 8), and irradiated plus fat grafting (irradiation, fat grafting, n = 9) groups were included. Hydrostatic pressures of the tissue expanders were measured before and immediately after expansion, and again postexpansion day 1. Pressure changes calculated as "postexpansion-relaxation interval": difference between maximal pressure at each expansion and the minimal pressure before the next expansion session. Differences were analyzed between groups.

RESULTS

Hydrostatic pressure plots reflect the soft tissue ability to accommodate sequential expansion. Fat grafted breasts demonstrated a statistically significant increased postexpansion-relaxation interval versus the nongrafted control group (P < 0.0001). Irradiated plus fat grafting breasts achieve similar postexpansion relaxation interval to the control group (P = 0.597). These changes are observed at postoperative week 6. Viscoelastic changes impact the overall expansion time: the fat grafted group achieved total expansion 2 weeks earlier than the nongrafted control group (P = 0.019). The fat grafted, radiated group completed expansion in similar time interval as nongrafted control group.

CONCLUSIONS

Observed viscoelastic changes impact the overall expansion time. Fat grafting in nonradiated mastectomy defects allows for shorter expansion period. Fat grating in radiated postmastectomy defects allows expansion durations equivalent to nonradiated, nonfat grafted control defects. There is a delayed effect of fat grafting observed at postoperative week 6.

Platelet Rich Plasma Hybridized Adipose Transplant (PHAT) for the Treatment of Hair Loss: A Case Series

BACKGROUND

Platelet-rich plasma (PRP) has long been used for the restoration of hair in conjunction with microneedling or on its own. Fat grafting to the scalp has also been utilized in the past to improve the quality of hair and the possibility of successful hair transplant. The novel therapy reported in this case series combines the natural progression of these two techniques and utilizes synergistic effects to improve the quality of hair, either in preparation for micrografting or without hair transplant.

OBJECTIVES

To demonstrate the principles behind the novel approach to restoration of hair and the rationale for its use.

METHODS

A review of the evidence for PRP and fat transfer for non-scarring alopecia serves as the foundation for the combination treatment reported herein. Through presentation of three cases in this series, we provide examples of the utility of this approach for non-scarring alopecia. This report includes a female who suffered non-scarring alopecia following COVID-19 hospitalization and intensive care stay where she lost a large percentage of her hair, in addition to two male patients suffering from androgenic alopecia.

RESULTS

Platelet-rich plasma-hybridized adipose transplant hair was shown in these three cases to improve both the quality and density of hair. It improved the density of hair in all patients and was characterized first by a short period of transient hair loss followed by new hair growth which develops starting at 4 weeks and was readily apparent at 12-week follow-up. Results were maintained at 6-month and 1-year follow-up.

CONCLUSIONS

PHAT hair offers a combination of beneficial effects-namely the unique healing properties and growth signaling provided by PRP, along with adipocyte angiogenic and growth signaling, which both work to improve scalp quality. The combination of these effects is better than previously characterized PRP injections alone in the hands of these individual practices. This may be due to synergistic interactions at a cellular level, but additional clinical studies are needed to better understand this novel treatment and the observed effects.

LEVEL OF EVIDENCE IV

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