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

Breast Lipofilling: Is the Bra Really Full? Clinical Bra Pressure Measurement and In Vitro Testing of Processed and Unprocessed Fat Cells

BACKGROUND

Breast lipofilling, a popular cosmetic and reconstructive procedure, involves the transplantation of autologous fat to enhance breast volume and contour. Despite its widespread use, cell processing and the aftertreatment remain controversial. This study investigates the pressure applied by a compression bra and reports in vitro stress tests of processed and unprocessed fat cells.

METHODS

Clinical bra pressure measurements were conducted on a cohort of 45 patients following lipofilling, reduction mammoplasties and DIEP flaps. Laboratory analysis included cell vitality testing using Resazurin assays of processed and unprocessed fat cells after exposure to mechanical or hyperbaric pressure.

RESULTS

Our findings show a mean overall pressure value of the compression bra for all patients of 6.7 ± 5.7 mmHg (range 0-35). Cell processing is superior to sedimentation only regarding fat cell vitality. However, neither mechanical pressure within the specified range nor hyperbaric oxygen exposure significantly affected fat graft survival as measured by Resazurin assays.

CONCLUSION

The in vitro measurements showed that it was impossible to harm fat cells with external pressure during lipofilling procedures, regardless of their processing. In the clinical context, the compression bra applied pressure values deceeding the perfusion pressure and may therefore not diminish oxygen supply nor harm the transplanted cells. Therefore, we recommend the use of a compression bra for all lipofilling procedures around the breast.

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 Table of Contents or online Instructions to Authors www.springer.com/00266.

Exosomes from Adipose-Tissue-Derived Stem Cells Induce Proapoptotic Gene Expression in Breast Tumor Cell Line

Lipofilling is an option for breast reconstruction after tumor resection to avoid the complications of an implant-based reconstruction. Although some concerns exist regarding the oncological safety of tissue rich in mesenchymal stem cells with their proangiogenic and proliferation-supportive properties, there are also reports that adipose-tissue-derived stem cells can exhibit antitumoral properties. We isolated primary adipose-tissue-derived stem cells. Both conditioned medium and exosomes were harvested from the cell culture and used to treat the breast cancer cell line MCF-7. Cell viability, cytotoxicity, and gene expression of MCF-7 cells in response to the indirect co-culture were evaluated. MCF-7 cells incubated with exosomes from adipose-tissue-derived stem cells show reduced cell viability in comparison to MCF-7 cells incubated with adipose-tissue-derived stem-cell-conditioned medium. Expression of proapoptotic genes was upregulated, and expression of antiapoptotic genes was downregulated. The debate about the oncological safety of autologous fat grafting after tumor resection continues. Here, we show that exosomes from adipose-tissue-derived stem cells exhibit some antitumoral properties on breast cancer cell line MCF-7.

Superior Sensibility after Full Breast Reconstruction with Autologous Fat Transfer

BACKGROUND

With developments in screening and treatment, survival rates of breast cancer patients are increasing, and so is the number of women opting for breast reconstruction to improve their quality of life. One factor that could play an important role in improving the quality of life is breast sensibility. Therefore, the aim of this study was to explore breast sensibility in participants of the Breast Reconstruction with External Preexpansion and Autologous Fat Transfer versus Standard Therapy trial: an ongoing randomized controlled trial comparing breast reconstruction with autologous fat transfer (AFT) versus implant-based reconstruction (IBR).

METHODS

This study was conducted on participants of the Breast Reconstruction with External Preexpansion and Autologous Fat Transfer versus Standard Therapy trial who were at least 12 months after final surgery. Semmes-Weinstein monofilaments were used to measure skin sensibility in breast cancer patients who underwent breast reconstruction with either AFT or IBR following their mastectomy.

RESULTS

A total of 46 patients were included in this study, resulting in 62 breast reconstructions (28 AFT breasts and 34 IBR breasts). Significantly higher mean monofilament values were found for skin sensibility after AFT (-0.7; P < 0.001), clinically correlating to "diminished protective function," as opposed to the IBR group, with clinical values indicating "loss of protective function."

CONCLUSIONS

In this study, the authors found that breast cancer patients who underwent a mastectomy had a significantly better sensibility of the breast following AFT for total breast reconstruction as compared with IBR. Larger studies that include null measurements are required to further explore these noteworthy results of AFT.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Imaging findings after a total reconstructed breast with autologous fat transfer: what the radiologist needs to know

Autologous fat transfer (AFT) is an upcoming technique for total breast reconstruction. Consequently, radiological imaging of women with an AFT reconstructed breast will increase in the coming years, yet radiological experience and evidence after AFT is limited.

The surgical procedure of AFT and follow-up with imaging modalities including mammography (MG), ultrasound (US), and MRI in patients with a total breast reconstruction with AFT are summarized to illustrate the radiological normal and suspicious findings for malignancy.

Imaging after a total breast reconstruction with AFT appears to be based mostly on benign imaging findings with an overall low biopsy rate. As higher volumes are injected in this technique, the risk for the onset of fat necrosis increases. Imaging findings most often are related to fat necrosis after AFT. On MG, fat necrosis can mostly be seen as oil cysts. The occurrence of a breast seroma after total breast reconstruction with AFT is an unfavourable outcome and may require special treatment. Fat deposition in the pectoral muscle is a previously unknown, but benign entity. Although fat necrosis is a benign entity, it can mimic breast cancer (recurrence).

In symptomatic women after total breast reconstruction with AFT, MG and US can be considered as first diagnostic modalities. Breast MRI can be used as a problem-solving tool during later stage. Future studies should investigate the most optimal follow-up strategy, including different imaging modalities, in patients treated with AFT for total breast reconstruction.

A Dutch randomized controlled study shows autologous fat transfer with pre-expansion is more cost-effective in the long term than implants

BACKGROUND

One in seven women will develop breast cancer, making it the most common female cancer worldwide. Consequently, breast cancer-related treatment, including breast reconstruction, impacts societal costs. Autologous fat transfer (AFT) is a relatively new breast reconstruction technique; however, several surgeries are necessary. This study investigates if AFT with pre-expansion is more cost-effective than implant-based reconstruction (IBR).

METHODS

Seven centers assigned patients randomly from 2015 to 2021 to evaluate costs and EQ-5D-5L quality-adjusted life years (QALY) of AFT vs. IBR at 12 months postoperative. Costs were calculated, including direct costs related to treatment and PROductivity and DISease Questionnaire, to estimate productivity loss (indirect costs). Sensitivity analyses were performed for 10- and 30 years to estimate costs for patients replacing or explanting their breast implants over time.

RESULTS

A total of 152 women, of which 91 received AFT (mean age 49.3) and 80 IBR (mean age 49.1). The mean EQ-5D-5L QALY in the AFT group was 0.83, compared with the IBR group of 0.79. Total costs for AFT at 12 months postoperative were higher than IBR (incremental cost: €6763.59). Sensitivity analyses for 10- and 30-year scenarios showed mean incremental costs of respectively €2586.56 and €680.22.

CONCLUSION

Mean EQ-5D-5L QALY and costs were higher for AFT over the first year after reconstruction. However, these costs were low; therefore, AFT was estimated to be more cost-effective over the 10- and 30-year period since no additional surgeries are necessary for this group. Larger cohorts are required to confirm AFT is more cost-effective in the long term.

Effect of Total Breast Reconstruction With Autologous Fat Transfer Using an Expansion Device vs Implants on Quality of Life Among Patients With Breast Cancer: A Randomized Clinical Trial

Importance

There is a need for a new, less invasive breast reconstruction option for patients who undergo mastectomy in their breast cancer treatment.

Objective

To investigate quality of life (QoL) among patients undergoing a new breast reconstruction technique, autologous fat transfer (AFT), compared with that among patients undergoing implant-based reconstruction (IBR).

Design, Setting, and Participants

The BREAST trial was a randomized clinical trial conducted between November 2, 2015, and October 31, 2021, performed in 7 hospitals across the Netherlands. Follow-up was 12 months. Referrals could be obtained from general practitioners and all departments from participating or nonparticipating hospitals. The patients with breast cancer who had undergone mastectomy and were seeking breast reconstruction were screened for eligibility (radiotherapy history and physique) by participating plastic surgeons. Patients receiving postmastectomy radiotherapy were excluded.

Interventions

Breast reconstruction with AFT plus expansion or 2-phased IBR. Randomization was done in a 1:1 ratio.

Main Outcomes and Measures

The statistical analysis was performed per protocol. The predefined primary outcome was QoL at 12 months after final surgery. This was measured by the BREAST-Q questionnaire, a validated breast reconstruction surgery questionnaire. Questions on the BREAST-Q questionnaire are scored from 0 to 100, with a higher score indicating greater satisfaction or better QoL (depending on the scale). Secondary outcomes were breast volume and the safety and efficacy of the techniques.

Results

A total of 193 female patients (mean [SD] age, 49.2 [10.6] years) 18 years or older who desired breast reconstruction were included, of whom 91 patients in the AFT group (mean [SD] age, 49.3 [10.3] years) and 80 in the IBR group (mean age, 49.1 [11.0] years) received the allocated intervention. In total, 64 women in the AFT group and 68 women in the IBR group completed follow-up. In the IBR group, 18 patients dropped out mainly due to their aversion to implant use while in the AFT group 6 patients ended their treatment prematurely because of the burden (that is, the treatment being too heavy or tiring). The BREAST-Q scores were higher in the AFT group in all 5 domains and significantly higher in 3: satisfaction with breasts (difference, 9.9; P = .002), physical well-being: chest (difference; 7.6; P = .007), and satisfaction with outcome (difference, 7.6; P = .04). Linear mixed-effects regression analysis showed that QoL change over time was dependent on the treatment group in favor of AFT. The mean (SD) breast volume achieved differed between the groups (AFT: 300.3 [111.4] mL; IBR: 384.1 [86.6] mL). No differences in oncological serious adverse events were found.

Conclusions and Relevance

This randomized clinical trial found higher QoL and an increase in QoL scores over time in the AFT group compared with the IBR group. No evidence was found that AFT was unsafe. This is encouraging news since it provides a third, less invasive reconstruction option for patients with breast cancer.

Trial Registration

ClinicalTrials.gov Identifier: NCT02339779.

Bilateral breast infection following total breast reconstruction with autologous fat transfer (AFT): A case report

INTRODUCTION AND IMPORTANCE

Total breast reconstruction with autologous fat transfer (AFT) has a low complication rate. Fat necrosis, infection, skin necrosis and hematoma are the most common complications. Infections are usually mild and manifested by a unilateral red painful breast and treated with oral antibiotics with or without superficial irrigation of the wound.

CASE PRESENTATION

One of our patients reported an ill-fitting pre-expansion device several days after surgery. This was due to a severe bilateral breast infection following a session of total breast reconstruction with AFT despite perioperative and postoperative antibiotic prophylaxis. Surgical evacuation was performed in combination with both systemic and oral antibiotic treatment.

CLINICAL DISCUSSION

Most infections can be prevented in the early post-operative period with antibiotic prophylaxis. If an infection does occur, it is treated with antibiotics or superficial irrigation of the wound. A delay in identification of an alarming course could be reduced by monitoring the fit to the EVEBRA device, implementing video consultations on indication, limiting the means of communication and better informing the patient on what complications to monitor. The recognition of an alarming course following a subsequent session of AFT is not guaranteed after a session without complication.

CONCLUSION

Besides temperature and redness of the breast, a pre-expansion device that doesn't fit can be an alarming sign. Patient communication should be adapted as severe infections can be insufficiently recognized by phone. Evacuation should be considered when an infection does occur.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Breast Autologous Fat Transfer Entirely Under Tumescent Anesthesia: Safety and Efficacy

BACKGROUND/OBJECTIVES

The prior use of external expansion has been described in the literature as a tool to allow reliable grafting of more than 200 mLs of autologous fat under general anesthesia. The purpose of this study was to determine whether breast autologous fat transfer entirely under tumescent anesthesia (BAFTEUTA) is a safe and effective technique.

METHODS

After institutional board approval, 22 consecutive patients were enrolled in this single-cohort, prospective study. All patients underwent preoperative expansion using manually evacuated domes. All procedures were performed under tumescent anesthesia with oral sedation.

RESULTS

There was a median successful graft of 200 mLs. Complications were minimal and limited to occlusive folliculitis.

CONCLUSION

Although the author has not reported as large graft volumes as some other authors, BAFTEUTA is a safe procedure and can have good outcomes with high levels of patient satisfaction.

Aesthetic Evaluation of Breast Reconstruction with Autologous Fat Transfer vs. Implants

Background

Autologous fat transfer (AFT) seems to be a new minimal invasive method for total breast reconstruction, yet how patients, surgeons, and laymen evaluate cosmesis is lacking. The aim of this study was to evaluate the aesthetic outcome of AFT (intervention group) for total breast reconstruction post-mastectomy, as compared to implant-based reconstruction (IBR) (control group).

Methods

A random and blinded 3D photographic aesthetic outcome study was performed on a selection of 50 patients, scored by three panels: plastic surgeons, breast cancer patients, and laymen. Secondary outcomes included agreement within groups and possible patient characteristics influencing scoring.

Results

Breast cancer patients and plastic surgeons did not differ in the aesthetic scores between the treatment groups. In contrast, the laymen group scored AFT patients lower than IBR patients (− 1.04, p < 0.001). Remarkably, mean given scores were low for all groups and overall agreement within groups was poor (ICC < 0.50). Higher scores were given when subjects underwent a bilateral reconstruction and if a mamilla was present.

Conclusion

Evaluation of aesthetic outcomes varies greatly. Hence, aesthetic outcome remains a very personal measure and this emphasizes the importance of thorough patient counseling including information on achievable aesthetic results before starting a reconstructive procedure.

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 .

SINGLE-CENTER ONCOLOGIC OUTCOME OF FAT TRANSFER FOR BREAST RECONSTRUCTION FOLLOWING MASTECTOMY IN 1000 CANCER CASES - A MATCHED CASE-CONTROL STUDY

BACKGROUND

Autologous fat transfer (AFT) has an important role in breast reconstructive surgery. Nevertheless, Some concerns remain with regards to its oncological safety. We present a single center case-matching study analysing the impact of AFT in cumulative incidence of local recurrences (LR).

MATERIALS AND METHODS

From a prospectively maintained database, we identified 902 patients who underwent 1025 breast reconstructions from 2005 to 2017. Data regarding demographics, tumor characteristics, surgery details and follow-up were collected. Exclusion criteria were patients with distant metastases at diagnosis, recurrent tumor or incomplete data regarding primary tumor, patients who underwent prophylactic mastectomies and breast-conserving surgeries. Statistical analysis was done to evaluate the impact of the variables on the incidence of LR. A p-value < 0.05 was considered statistically significant.

RESULTS

After 1:n case-matching, we selected 919 breasts, out of which 425 (46.2%) patients received at least one AFT session vs 494 (53.8%) control cases. LR had an overall rate of 6.8% and we found LR in 14 (3.0%) AFT cases and 54 (9.6%) controls. Statistical analysis showed that AFT did not increase risk of LR: HR 0.337 (CI 0.173-0.658), p=0.00007. Multivariate analysis identified IDC subtype and lymph node metastases to have an increased risk of local recurrences (HR > 1). Conversely, positive hormonal receptor status was associated with a reduced risk of events (HR < 1).

CONCLUSIONS

AFT was not associated with a higher probability of locoregional recurrence in patients undergoing breast reconstruction therefore it can be safely used for total breast reconstruction or aesthetic refinements.LEVEL OF EVIDENCE: 3.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

The majority of surgeons choose an implant-based breast reconstruction after mastectomy. Nevertheless, lipofilling is a constantly growing technique allowing a complete breast reconstruction without prosthesis. We introduce our experience using reverse expansion for breast reconstruction following a nipple-sparing mastectomy (NSM) with a subpectoral skin expander. In the period January 2010-August 2021, 106 breast reconstruction procedures were performed on 50 patients after a NSM. We harvested an amount of fat tissue using a 2.5 mm liposuction cannula, we centrifuged it 3 min at 4000 rpm and injected in the recipient site using 3 ml syringes and Coleman cannulas. At the beginning of every session, the breast expander was deflated of a saline volume similar to the one of the fat to be injected. We harvested an average of 679.2 ccs of fat per session and injected an average of 319.3 ccs per breast. The mean number of sessions has been 2.4 per breast. The average number of sessions in a radiotreated patients' subgroup has been slightly higher than a control group. The mean follow-up time was 63.5 months and we observed no complications in 105 over 106 procedures. Lipofilling has proven to be a safe and effective technique for complete breast reconstruction. Our procedure considers the use of a breast expander as a device to prepare the recipient site. Reverse expansion after a NSM allows a like-with-like reconstruction and it might be the first reconstructive choice in a selected group of patients.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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

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

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Donor Site Satisfaction Following Autologous Fat Transfer for Total Breast Reconstruction

BACKGROUND

With evolving breast cancer survival and patient preferences, it is essential that reconstructive surgeons worldwide continue searching for the best reconstruction technique for patients. Autologous fat transfer (AFT) is a relatively new technique for total breast reconstruction that has already proven to be effective and safe with all advantages of autologous tissue. However, little is known about the aesthetic results and satisfaction concerning donor sites.

OBJECTIVES

The aim of this study was to measure donor site satisfaction following AFT for total breast reconstruction in breast cancer patients.

METHODS

Between May and August of 2021, participants of the BREAST- trial who were at least 24 months after their final reconstruction surgery were invited to complete an additional survey concerning donor sites. The BODY-Q was utilized for data collection. Results of AFT patients were compared with a control group of implant-based reconstruction patients who did not have a donor site.

RESULTS

A total of 51 patients (20 control, 31 intervention) completed the questionnaire. Satisfaction with body did not statistically differ between the groups. The most frequent complaint was contour irregularities (31 reports, 60.8%), with the least favorable donor site being thighs (23 reports, 53.5%) in the AFT group.

CONCLUSIONS

Satisfaction with body did not differ between breast cancer patients receiving AFT or implant-based reconstruction, meaning that large-volume liposuction does not aesthetically affect the utilized donor sites. Nevertheless, reconstructive surgeons should be aware of possible donor site complications, especially contour irregularities at the thighs, and discuss this with their patients.

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.

[Research progress of external volume expansion assisted autologous fat grafting for breast reconstruction]

OBJECTIVE

To review the application progress, mechanism, application points, limitations, and oncological safety of external volume expansion (EVE) assisted autologous fat grafting for breast reconstruction and provide a reference for optimizing the design of EVE.

METHODS

Based on the latest relevant articles, the basic experiments and clinical applications of EVE were summarized.

RESULTS

EVE can reduce interstitial fluid pressure, increase blood supply, and promote adipogenic differentiation, thereby benefiting the survival of transplanted fat. EVE assisted autologous fat grafting in clinical practice can improve the retention rate of breast volume and the outcome of breast reconstruction, meanwhile it doesn't increase the risk of local recurrence. But there is no standard parameters for application, and there are many complications and limitations.

CONCLUSION

EVE improves the survival of transplanted fat, but its complications and poor compliance are obvious, so it is urgent to further investigate customized products for breast reconstruction after breast cancer and establish relevant application guidelines.

Breast Reconstruction by Exclusive Lipofilling after Total Mastectomy for Breast Cancer: Description of the Technique and Evaluation of Quality of Life

Background: The objective of this work was to describe the technique of exclusive lipofilling in breast reconstruction after total mastectomy, to evaluate the satisfaction and quality of life of the patients, and to explore current literature on the subject. Methods: We conducted a retrospective observational multicentric study from January 2013 to April 2020. The modalities of surgery, esthetic result, and patient satisfaction were evaluated with the breast reconstruction module of BREAST-Q. Results: Complete data were available for 37 patients. The mean number of sessions was 2.2 (standard deviation 1.1), spread over an average of 6.8 months (SD 6.9). The average total volume of fat transferred was 566.4 mL. The complication rate was 18.9%. No severe complication was observed (Clavien–Dindo 3/4). Two patients were diagnosed with recurrence, in a metastatic mode (5.4%). The average satisfaction rate was 68.4% (SD 24.8) for psychosocial well-being and 64.5% (SD 24.1) for sexual well-being. The satisfaction rate was 60.2% (SD 20.9) for the image of the reconstructed breast and 82.7% (SD 21.9) for locoregional comfort. Conclusions: Breast reconstruction by exclusive lipofilling after total mastectomy provides satisfactory quality of life scores. The simplicity of the surgical technique and equipment required, and the high satisfaction rate confirm that lipofilling should be included in the panel of choice of breast reconstruction techniques.

Oncologic safety of breast reconstruction with autologous fat grafting: A systematic review and meta-analysis

BACKGROUND

Autologous fat grating has become increasingly popular as a breast reconstructive procedure. Nevertheless, preclinical studies show that fat transfer to a previous breast cancer site could activate latent cancer cells, creating a favourable environment for disease recurrence. A systematic review and meta-analysis was performed to investigate whether fat grafting increases the risk of locoregional recurrence in patients formerly treated for breast cancer.

METHODS

Based on PRISMA guidelines, a systematic review searching for randomised clinical trials and matched cohorts on the topic was performed in the electronic databases Pubmed, Embase, Web of Science, and Cochrane. The date of the last search was July 20, 2021. The meta-analysis assessed the comparison of locoregional recurrence between groups.

RESULTS

From a total of 558 publications, data from nine matched cohorts (1.6%) reporting on 4247 subjects (1590 and 2657 subjects, respectively, in lipofilling and control groups) were suitable for inclusion in the meta-analysis. Neither of the outcomes had a statistically significant difference for disease recurrence. For the primary outcome, comparing locoregional recurrence rates between groups, the incidence rate ratio was 0.92 (95% CI: 0.68-1.26; P = 0.620).

CONCLUSION

The present meta-analysis, which comprises the outcomes of the individual studies with the best current evidence on the topic so far, strengthens the evidence favouring the oncologic safety of lipofilling for breast reconstruction.

UK Guidelines for Lipomodelling of the Breast on behalf of Plastic, Reconstructive and Aesthetic Surgery and Association of Breast Surgery Expert Advisory Group

Lipomodelling has become increasingly popular for reconstructive, aesthetic and therapeutic indications. The guidelines summarise available evidence for indications, training, technique, audit and outcomes in lipomodelling and also highlight areas for further research.

Autologous fat grafting for breast reconstruction after breast cancer: a 12-year experience

Purpose

The aim of our study was to examine the surgical outcome and complications (efficiency) as well as the incidence of locoregional recurrence and distant metastases (oncological safety) in patients who underwent autologous fat grafting (AFG) of the breast following breast cancer surgery.

Methods

In our monocentric cohort study, retrospective and prospective data were collected from all consecutive patients who underwent AFG after breast cancer between 2008 and 2020; a total of 93 patients met the inclusion criteria.

Results

Our long-term results showed no increase in tumor recurrence and distant metastases in the studied collective when compared to the available literature. We observed 1 local recurrence (1.1%), 2 distant metastases (2.2%), and 1 tumor-related death (1.1%). There was a high degree of patient satisfaction; 67.12% of patients reported adequate satisfaction with autologous fat grafting.

Conclusion

Currently, to our knowledge, this is the study with the longest follow-up time (mean 6.7 years after AFG and 11.5 years after tumor resection). The results of our clinical study will contribute to improve evidence in the broad field of AFG, adipose stem cell and tumor research. Consistent with our study, the literature review shows a clear tendency of clinical trial results with a low incidence rate of tumor recurrence and metastasis following the use of AFG. AFG seems to be a safe procedure also after breast cancer treatment.

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 3

Cryopreservation of adipose tissue with and without cryoprotective agent addition for breast lipofilling: A cytological and histological study

In the second reconstructive phase of the breast after mastectomy, lipofilling is often necessary. Currently, lipofilling occurs immediately after autologous adipose tissue harvesting procedure, but most of the patients, usually, require multiple sessions to obtain a satisfactory result. Therefore, the need of repeated surgical harvesting outputs implies high risk of patients' morbidity and discomfort as well as increasing medical time and costs. The aim of our pilot study was to find out a feasible method to cryopreserve adipose tissue, in order to avoid reiterated liposuctions. Lipoaspirates samples have been harvested from 10 women and preserved by three methods: (1) the first one, using 10% Me₂SO and 20% human albumin from human plasma as cryoprotective agents; (2) the second one, adding 5% Me₂SO as cryoprotective agent; 3) the last one, without any cryoprotective agent. Fresh and cryopreserved fat samples, obtained through the aforementioned processes, have been analyzed ex vivo. The efficiency of the cryopreservation methods used was determined by adipocyte viability and the expression of adipocytes surface markers. Lipoaspirates stored at -196 °C for 3 months, after thawing, retained comparable adipocyte viability and histology to fresh tissue and no significant differences were found between the three methods used. Although the current results, differences between the methodologies in terms of viability may not become evident until breast lipofilling using frozen-thawed cryopreserved tissue.

Autologous Fat Grafting for Oncologic Patients: A Literature Review

Autologous fat grafting (AFG) serves as an effective method to address volume defects, contour irregularities, and asymmetry in both aesthetic and reconstructive procedures. In recent years, there has been growing concern about the potential of cancer recurrence and interference with cancer surveillance in oncologic patients receiving AFG. The adipose tissue contains adipose-derived stem cells (ASCs), a specific type of mesenchymal stem cells, that facilitate secretion of numerous growth factors which in turn stimulate tissue regeneration and angiogenesis. As such, it has been theorized that ASCs may also have the potential to stimulate cancer cell proliferation and growth when used in oncologic patients. Multiple research studies have demonstrated the ability of ACSs to facilitate tumor proliferation in animal models. However, clinical research in oncologic patients has yielded contradictory findings. Although the literature pertaining to oncologic safety in head and neck, as well as sarcoma, cancer patients remains limited, studies demonstrate no increased risk of tumor recurrence in these patient populations receiving AFG. Similarly, both the efficacy and safety of AFG have been well established in breast cancer patients through numerous clinical studies. More recently, preclinical research in animal models has shown that AFG has the potential to facilitate tissue regeneration and improve joint contracture following irradiation. Ultimately, further research is needed to elucidate the safety of AFG in a variety of oncologic patients, as well as explore its use in tissue regeneration, particularly in the setting of radiotherapy. Level of Evidence: 4.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Oncologic Safety of Autologous Fat Grafting in Breast Reconstruction

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

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.

Autologous fat transfer to treat fibrosis and scar-related conditions: A systematic review and meta-analysis

BACKGROUND

Autologous fat transfer (AFT), also known as lipofilling, has been demonstrated to be more than just a filler. Through both mechanical dissection and local tissue remodelling mediated by stem cells, it is thought to improve scar quality, function and even pain. This paper aims to investigate the evidence regarding its safety and effectiveness for treating fibrosis and scar-related conditions.

METHODS

A literature search was performed in PubMed, Embase and the Cochrane Library to identify relevant studies. Extensive data extraction and standardization allowed conducting a meta-analysis.

RESULTS

Forty-five studies (3033 patients) provided sufficient data for meta-analysis. The AFT treatment resulted in significant increase in satisfaction scores of both patient and surgeon (p  =  0.001). Furthermore, a significant overall scar improvement was also found in the evaluation using the Patient and Observer Scar Assessment Scale, with the most notable effect in the scar stiffness (p<0.001) and pliability (p  =  0.004). In patients with severe pain, AFT resulted in a significant pain reduction of 3.7 points on the Visual Analogue Scale (p<0.001). Last, but not the least, the evidence suggests a significant recovery of radiotherapy-induced tissue damage (p  =  0.003) and function (p  =  0.012). On average, 1.4 procedures were required to achieve the desired result. Minor complications occurred in 4.8% of the procedures.

CONCLUSIONS

AFT is a promising treatment for fibrosis and scar-related conditions. Future research should focus on determining the long-term effects of AFT on fibrosis, pain and function. In addition, it would be crucial to quantify the mechanical and regenerative properties of fat as well as the effect of added supplements or stem cells.

Application of Fat Grafting in Cosmetic Breast Surgery

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

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

IMPORTANCE

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

OBJECTIVE

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

DESIGN

Matched retrospective cohort study.

SETTING

Tertiary referral center.

PARTICIPANTS

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

MAIN OUTCOME(S) AND MEASURE(S)

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

RESULTS

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

CONCLUSIONS AND RELEVANCE

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

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

INTRODUCTION

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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