Long-term impact of lipofilling in hybrid breast reconstruction: retrospective analysis of two cohorts

Postmastectomy Breast Reconstruction in Patients with Non-Metastatic Breast Cancer: A Systematic Review

Breast reconstruction after mastectomy improves the quality of life for many patients with breast cancer. There is uncertainty regarding eligibility criteria for reconstruction, timing (immediate or delayed-with or without radiotherapy), outcomes of nipple-sparing compared to skin-sparing mastectomy, selection criteria and surgical factors influencing outcomes of nipple-sparing mastectomy, prepectoral versus subpectoral implants, use of acellular dermal matrix, and use of autologous fat grafting. We conducted a systematic review of these topics to be used as the evidence base for an updated clinical practice guideline on breast reconstruction for Ontario Health (Cancer Care Ontario). The protocol was registered on PROSPERO, CRD42023409083. Medline, Embase, and Cochrane databases were searched until August 2024, and 229 primary studies met the inclusion criteria. Most studies were retrospective non-randomized comparative studies; 5 randomized controlled trials were included. Results suggest nipple-sparing mastectomy is oncologically safe, provided there is no clinical, radiological, or pathological indication of nipple-areolar complex involvement. Surgical factors, including incision location, may affect rates of complications such as necrosis. Both immediate and delayed reconstruction have similar long-term outcomes; however, immediate reconstruction may result in better short to medium-term quality of life. Evidence on whether radiotherapy should modify the timing of initial reconstruction or expander-implant exchange was very limited; studies delayed reconstruction after radiotherapy by at least 3 months and, more commonly, at least 6 months to avoid the period of acute radiation injury. Radiation after immediate reconstruction is a reasonable option. Surgical complications are similar between prepectoral and dual-plane or subpectoral reconstruction; prepectoral placement may give a better quality of life due to lower rates of long-term complications such as pain and animation deformity. Autologous fat grafting was found to be oncologically safe; its use may improve quality of life and aesthetic results.

Assessing Fat Grafting in Breast Surgery: A Narrative Review of Evaluation Techniques

Fat grafting has gained prominence in reconstructive and aesthetic surgery, necessitating accurate assessment methods for evaluating graft volume retention. This paper reviews various techniques for assessing fat and fat grafts, including their benefits and limitations. Three-dimensional (3D) scanning offers highly accurate, non-invasive volumetric assessments with minimal interference from breathing patterns. Magnetic resonance imaging (MRI) is recognized as the gold standard, providing precise volumetric evaluations and sensitivity to complications like oil cysts and necrosis. Computed tomography (CT) is useful for fat volume assessment but may overestimate retention rates. Ultrasonography presents a reliable, non-invasive method for measuring subcutaneous fat thickness. Other methods, such as digital imaging, histological analysis, and weight estimation, contribute to fat graft quantification. The integration of these methodologies is essential for advancing fat graft assessment, promoting standardized practices, and improving patient outcomes in clinical settings.

Pre-pectoral Breast Reconstruction: Surgical and Patient-Reported Outcomes of Two-Stages vs Single-Stage Implant-Based Breast Reconstruction

BACKGROUND

Two-stages pre-pectoral breast reconstruction may confer advantages over direct to implant (DTI) and subpectoral reconstruction in selected patients who have no indication for autologous reconstruction. The primary endpoint of the study was to evaluate and compare the incidence of capsular contracture in the pre-pectoral two-stages technique versus the direct to implant technique. Complications related to the two surgical techniques and patient satisfaction were also evaluated.

METHODS

A retrospective review of 45 two stages and 45 Direct-to-implant, DTI patients was completed. Acellular dermal matrix was used in all patients. An evaluation of anthropometric and clinical parameters, surgical procedures and complications was conducted. Minimum follow-up was 12 months after placement of the definitive implant.

RESULTS

There was no statistically significant difference in the rate of capsular contracture in the two groups. Rippling occurred more in DTI reconstruction. In the two-stages reconstruction, lipofilling was applied more often and there was a higher incidence of seroma. Patient satisfaction extrapolated from the Breast Q questionnaire was better for patients submitted to two-stage implant-based breast reconstruction.

CONCLUSION

Dual-stage pre-pectoral reconstruction with acellular dermal matrix appears to be a good reconstructive solution in patients with relative contraindications for one-stage heterologous reconstruction with definitive prosthesis and no desire for autologous reconstruction.

The Efficacy of Fat Grafting on Treating Post-Mastectomy Pain with and without Breast Reconstruction: A Systematic Review and Meta-Analysis

Post-mastectomy pain syndrome (PMPS), characterized by persistent pain lasting at least three months following mastectomy, affects 20-50% of breast surgery patients, lacking effective treatment options. A review was conducted utilizing EMBASE, MEDLINE, and all evidence-based medicine reviews to evaluate the effect of fat grafting as a treatment option for PMPS from database inception to 29 April 2023 (PROSPERO ID: CRD42023422627). Nine studies and 812 patients in total were included in the review. The overall mean change in visual analog scale (VAS) was -3.6 in 285 patients following fat grafting and 0.5 in 147 control group patients. There was a significant reduction in VAS from baseline in the fat grafting group compared to the control group, n = 395, mean difference = -2.17 (95% CI, -2.95 to -1.39). This significant improvement was also noted in patients who underwent mastectomy without reconstruction. Common complications related to fat grafting include capsular contracture, seroma, hematoma, and infection. Surgeons should consider fat grafting as a treatment option for PMPS. However, future research is needed to substantiate this evidence and to identify timing, volume of fat grafting, and which patient cohort will benefit the most.

Stem Cell-Enriched Hybrid Breast Reconstruction Reduces Risk for Capsular Contracture in a Hybrid Breast Model

BACKGROUND

Hybrid breast reconstruction (HBR) combines silicone implants with fat grafting to improve implant coverage, treating local tissue deficiencies and leading to a more natural breast appearance. Recent data also indicated less capsular contracture after HBR. The authors developed a novel technique and animal model of cell-assisted (CA) HBR to illuminate its effects on capsular contracture.

METHODS

Animals received silicone implants in a dorsal submuscular pocket. Although animals of the HBR group received fat grafting around the implant without stem cell enrichment, rats of the CA-HBR1 and the CA-HBR2 groups received stem cell-enriched fat grafting with 2 × 10 6 and 4 × 10 6 adipose-derived stem cells immediately after implant insertion. On day 60, animals underwent sonography and elastography imaging and were euthanized, and outcome analysis was performed by means of histology, immunohistochemistry, chemical collagen quantification, and gene expression analysis.

RESULTS

With this novel technique, long-term survival of adipose-derived stem cells within the implant pocket was demonstrated after 60 days after implant insertion. CA-HBR led to significantly reduced thickness and collagen density of capsular contractures. In addition, CA-HBR resulted in reduced fibrotic responses with less occurrence of collagen type I and transforming growth factor-β in capsule tissue. Moreover, the addition of stem cells suppressed fibrotic and inflammatory responses on a genetic level with significant underexpression of collagen type I and transforming growth factor-β1.

CONCLUSIONS

With this new technique and animal model, the authors observed a preventive effect on capsular contracture substantiating the basis of clinical outcomes of HBR. The authors propose that the addition of stem cells to HBR might booster its beneficial results.

CLINICAL RELEVANCE STATEMENT

Stem cell-enriched fat grafting around silicone implants may reduce the risk for capsular contracture after silicone breast implantation. While fat grafting alone already shows beneficial effects, the addition of stem cells to the fat graft can potentiate this effect.

Effective or Harmful-Evaluation of Locally Applied Antibiotics on Adipose Tissue during Lipofilling to the Breast-An In Vitro Study

Lipofilling is a frequently used and safe procedure for breast reconstruction. One of the most feared complications is soft tissue infection following lipofilling. Because of this, some surgeons propose the practice of rinsing fat grafts with antibiotics. This study investigates the effect of antibiotic rinses on fat grafts in an in vitro model. Adipocytes and stem cells were isolated from fat tissue harvested during 24 lipofilling procedures and incubated with different doses of clindamycin or cefazolin. Cell viability, metabolism, proliferation, and differentiation capacities were analyzed by gross morphology, fluorescence staining, -(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazoliumbromid (MTT-), and Glyceraldehyde 3 Phosphate Dehydrogenase (G3PD)-assay as well as reactive oxygen species (ROS)-assay. Cefazolin and clindamycin led to significant reduction of cell viability of adipocytes. High doses of both antibiotics led to a rupture of adipocytes with visible free lipid droplets. Cell metabolism was significantly decreased after incubation with both antibiotics. There was a significant increase in ROS production. Exposure to clindamycin and cefazolin led to morphological changes in stem cells in a dose- and time-dependent manner. Furthermore, differentiation potential was significantly reduced. Antibiotic susceptibility testing, however, showed that low concentrations of antibiotics effectively inhibited bacterial growth in contaminated fat grafts. This study confirms that rinsing fat grafts with clindamycin or cefazolin not only overly prevents infection but also has cytotoxic and metabolic effects on adipocytes. Therefore, based on these results, the routine clinical application in high doses cannot be recommended.

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).

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

Background:

Breast reconstruction is currently performed as standard practice.

Methods:

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

Results:

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

Conclusions:

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

Lipofilling in Breast Oncological Surgery: A Safe Opportunity or Risk for Cancer Recurrence?

Lipofilling (LF) is a largely employed technique in reconstructive and esthetic breast surgery. Over the years, it has demonstrated to be extremely useful for treatment of soft tissue defects after demolitive or conservative breast cancer surgery and different procedures have been developed to improve the survival of transplanted fat graft. The regenerative potential of LF is attributed to the multipotent stem cells found in large quantity in adipose tissue. However, a growing body of pre-clinical evidence shows that adipocytes and adipose-derived stromal cells may have pro-tumorigenic potential. Despite no clear indication from clinical studies has demonstrated an increased risk of cancer recurrence upon LF, these observations challenge the oncologic safety of the procedure. This review aims to provide an updated overview of both the clinical and the pre-clinical indications to the suitability and safety of LF in breast oncological surgery. Cellular and molecular players in the crosstalk between adipose tissue and cancer are described, and heterogeneous contradictory results are discussed, highlighting that important issues still remain to be solved to get a clear understanding of LF safety in breast cancer patients.

Suspected breast implant rupture: our experience, recommendations on its management and a proposal for a model of informed consent

Background

Implant rupture may be detected by physical examination, ultrasound or magnetic resonance imaging (MRI); the majority of silicone implant ruptures are clinically undetectable. The absence of guidelines for behaviour in the face of a suspected implant rupture often entails sending these patients for prosthetic revision surgery rather than carrying out in-depth radiodiagnostics to confirm implant rupture. The aim of this paper is to report our multicentric experience, to indicate the correct diagnostic-therapeutic procedure and to propose a model of informed consent.

Methods

We conducted a multicentric retrospective analysis of 183 women submitted to prosthetic revision surgery due to radiological diagnosis of suspected implant rupture after breast augmentation or post-mastectomy reconstruction, admitted to three different Plastic Surgery Departments between 2002 and 2018. We correlated surgical findings with purpose of examination, symptoms, physical examination, imaging and device specifications.

Results

Two hundred and twenty-one explanted implants were preoperatively suspected as ruptured. One-third were intact and unjustifiably explanted. US associated with MRI evaluation was the most accurate method. Patient’s age, comorbidities, smoking, medications, symptoms presented, implant duration and volume did not correlate with implant rupture.

Conclusions

Our study confirms that the association of US and MRI represents the mode of diagnosis with fewest false positives. Given the high number of errors associated with suspected intracapsular implant rupture, it seems necessary to submit an appropriate and specific informed consent that takes into account the emotional component and clearly and completely explains the possible alternatives and complications associated with possible prosthetic revision surgery.

Level of evidence: Level III, risk/prognostic study