International Expert Panel Consensus on Fat Grafting of the Breast

Attenuated Angiogenesis and Macrophage Infiltration during Adipose Tissue Regeneration in Megavolume Human Fat Grafting

BACKGROUND

Survival and regeneration mechanisms of large (>250 mL) fat grafts remain incompletely understood. In fat grafts from volunteers with megavolume fat transfer breast augmentation, neovascularization and inflammatory cell infiltration decreased within 7 days according to histologic analysis. The authors further investigated this phenomenon using a nude mouse model.

METHODS

To simulate clinical contexts, chambers containing 1 mL of human fat were implanted into nude mice. Chambers allowed selective transfer of tissue fluid from recipient nude mice into chambers, but not capillaries or macrophages. Seven days later, fat was removed from the chamber and reimplanted into a new nude mouse in the open-chambered fat group (OCFG) ( n = 45). Adipose samples from volunteers and explanted grafts from OCFG were subjected to histologic analyses. Graft weight, vascularization, and immune response were also compared between the OCFG and conventional direct fat grafting (control group [CG]).

RESULTS

Percentage tissue integrity, percentage fibrosis, adipocyte viability, and neovascularization did not significantly differ between volunteer samples and OCFG grafts at day 7. On day 90, OCFG retention rate was decreased relative to the CG, and the fibrosis area was larger in the OCFG than in the CG. However, the macrophage and capillary counts were lower in the OCFG group relative to the CG at days 7 and 14 after transplantation.

CONCLUSIONS

The present study provides histologic analyses of megavolume fat grafts sampled from clinical breast augmentation tissues and a xenograft nude mouse model. However, these preliminary results in a small clinical cohort should be further assessed in large allogeneic animal models.

CLINICAL RELEVANCE STATEMENT

The results of this study will help surgeons understand the early regeneration of transplanted fat after large volume fat grafting for breast augmentation.

Optimal Strategies for Autologous Fat Grafting in Breast Augmentation and Reconstruction: A Systematic Review and Network Meta-Analysis

BACKGROUND

Cell-assisted lipotransfer (CAL) and platelet-rich plasma (PRP)-assisted lipotransfer have been used to overcome the low survival rate of conventional lipotransfer. However, there is still insufficient evidence to determine which technique is the best strategy for autologous fat grafting in breast cosmetic and reconstructive surgery. The present study aimed to compare the efficacy of traditional fat transplantation, CAL, and PRP-assisted lipotransfer.

METHODS

A systematic search was conducted in several databases, including PubMed, Web of Science, Cochrane, ClinicalTrials.gov, and Embase, concluding on January 21, 2024, to identify studies that met the inclusion criteria. Twelve studies were included after a rigorous selection process based on predefined criteria. Statistical analyses were conducted using R version 4.0.5 software with the netmeta and dmetar packages, utilizing a frequentist approach with a random-effects model. A network meta-analysis was performed to compare different fat graft procedures with regard to fat survival rate and complication events.

RESULTS

CAL and PRP-assisted lipotransfer were better than traditional fat grafting in terms of fat survival rate. In addition, there was no significant difference in the incidence of postoperative complications among the CAL, PRP, and traditional groups.

CONCLUSIONS

Given the results of network meta-analysis, it appears that both CAL and PRP-assisted lipotransfer have a higher fat survival rate for autologous fat grafting in breast augmentation and reconstruction. However, the transplantation strategy still needs to be analyzed based on actual conditions in clinical applications.

Vascular Endothelial Growth Factor Expression of Adipose-Derived Stromal Cells and Adipocytes Initiated from Fat Aspirations

BACKGROUND

Fat grafting is frequently employed in aesthetic and reconstructive plastic surgery with a low complication rate. However, fat necrosis may occur in dependence of the mode of fat aspiration, processing of the tissue and graft size. Graft survival is critically dependent on the contained adipose-derived stromal cells (ADSCs), adipocyte precursors and their potential for vascular supply. This work investigated the potential role of the expression of vascular endothelial growth factor A (VEGF) and various cytokines by ADSCs and differentiated adipocytes as key factors of fat grafting.

METHODS

Adipokine expression of ADSCs and differentiated adipocytes were assessed using Proteome Profiler Arrays that detect 58 relevant proteins.

RESULTS

Collected fat grafts could be categorized according to their adipokine expression into VEGFhigh and VEGFlow ADSCs groups, the former exhibiting higher content of VEGF-related angiopoietin-like 2, nidogen-1/entactin, CCL2/MCP-1 and elevated expression of IGFBPs in association with a fourfold higher VEGF expression. Differentiation of ADSCs into adipocytes increased VEGF concentrations in VEGFlow ADSCs but not in ADSCs exhibiting initial high VEGF concentrations. The adipocytes revealed high expression of HGF, leptin, CCL2/MCP-1, nidogen-1/entactin, M-CSF but lower induction of angiopoietin-like 2.

CONCLUSION

Half of the ADSCs from fat grafts express high concentrations of VEGF and other adipokines that support angiogenesis and survival of this tissues following transfer. Differentiation of ADSClow cells to adipocytes may make up for the initially low VEGF expression, but this activation is 7-10 days delayed compared to the VEGFhigh ADSC cells and may fail to support angiogenesis from the beginning.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Fat Grafting to the Breast for Aesthetic Indications: Techniques and Outcomes in 165 Consecutive Patients

PURPOSE

Fat grafting to the breast for aesthetic indications has become increasingly popular. Herein, methods, aesthetic outcomes, and complications are reviewed in a retrospective case series.

METHODS

Female patients (n=165) with an average age of 45 years (range: 17-78 years) who underwent fat grafting to breast were evaluated. Demographic parameters, the type of procedure, the amount of fat transferred, the site(s) of fat harvest, operative times, and the patient's postoperative recovery and outcomes were recorded.

RESULTS

Of the 165 patients, 105 had breast augmentation with fat only. Of these 105 patients, 14(8%) had implant removal with and without capsulectomy, and 61(37%) had mastopexies. Composite augmentation was performed in the remaining 60 patients. The average amount of fat used was 208 cc (range: 10 to 945 cc) per breast. Forty-five patients (27%) underwent a second procedure. Of the 165 patients, 37(22%) had adverse events unrelated to the fat graft, including suture abscesses, scarring, and minor incision cite skin breakdown. Four patients (2.4%) had a complication related to fat grafting including 'lump' formation between the breast, abnormal mammograms, and the need for simple aspiration of a lipid cyst.

CONCLUSIONS

Autologous fat grafting should be considered for both primary and secondary aesthetic breast surgery to enhance outcomes. Complications related to fat grafting are uncommon. Revisional and secondary surgeries may be needed to achieve the desired outcome. Power-assisted liposuction, with vibratory infiltration of the tumescent solution, auto-infusion of fat, and Expansion Vibration Lipofilling using a closed system has become our preferred technique. Fat grafting to breast can be considered for both primary and secondary aesthetic breast surgery Complications related to fat grafting are uncommon There does not appear to be an overall increase in complications of associated mastopexy and composite augmentation LEVEL OF EVIDENCE V: 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 .

Hybrid Breast Augmentation: Double Benefit or Double Risk? A Comparative Study of 932 Cases

BACKGROUND

The authors propose a hybrid breast augmentation (HBA) method combining implants and fat grafting and explore the outcome and safety through a retrospective, single-center, propensity score-matched, comparative study.

METHODS

Outcome, satisfaction, and complications were compared between the HBA group (302 cases) and the implant-based breast augmentation (IBA) group (353 cases), and between the HBA group and the autologous fat grafting (AFG) group (277 cases).

RESULTS

The mean follow-up period was 31.7 months. After propensity score matching (PSM), 270 cases were matched between the HBA and IBA groups, and 156 cases were matched between the HBA and AFG groups. Compared with the IBA group, HBA achieved higher scores of implant visibility/palpability and upper pole contour with the specialists' evaluations (before and after PSM; P < 0.05). Regarding patient satisfaction, the scores of softness (before and after PSM), smoothness of the upper pole (before PSM), and overall satisfaction (after PSM) of the HBA group were better ( P < 0.05). Implant-related complications occurred at a similar rate. Compared with the AFG group, HBA achieved higher scores of shape (before and after PSM) and symmetry (after PSM) with evaluations by specialists ( P < 0.05). The scores of shape, symmetry, and overall satisfaction in the HBA group were better (before and after PSM; P < 0.05). The HBA group showed a lower incidence of palpable cysts, fat necrosis, oil cysts, and fat calcification (before PSM; P < 0.05).

CONCLUSION

When the three techniques were compared objectively, HBA presented better indices of aesthetic outcomes, satisfaction, and acceptable complications rates when compared with IBA and AFG.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Total Breast Reconstruction with Lipofilling after Traditional Mastectomy without the Use of Tissue Expanders

BACKGROUND

Lipofilling can be used to reconstruct a breast without additional implants or autologous composite grafts. However, methods to maximize retention of the transferred fat remain under debate. Here, the authors present their experience of breast reconstruction with lipofilling without concomitant use of tissue expanders.

METHODS

Patients who had completed breast reconstruction with lipofilling between June of 2010 and June of 2016 were reviewed. Those with obtainable follow-up magnetic resonance imaging scans were included in this cross-sectional study. The hospital records were reviewed for details of the lipofilling operations. Magnetic resonance imaging scans were evaluated for the volume retention and quality of the transferred fat. The patients were asked to assess the appearance and sensitivity of the reconstructed breast, the recovery time, and any adverse effects at the fat donor area.

RESULTS

Thirty-eight women with 41 reconstructed breasts were included in the study. The median age at follow-up was 62 years (range, 48 to 78 years). They had undergone a median of four (range, two to six) lipofilling procedures with a median total volume 690 mL (range, 369 to 1350 mL). After a median follow-up of 2.1 years (range, 0.4 to 6.8 years), the median proportion of transferred fat retained was 58% (range, 14% to 119%), representing a reconstructed breast volume of 76% (range, 17% to 100%) of the contralateral breast. Oil cysts larger than 10 mm were detected in 7%. Most patients reported being satisfied with the reconstructed breast and experienced few side effects.

CONCLUSIONS

Breast reconstruction with lipofilling can be performed with an acceptable number of procedures and no preoperative skin expansion. It extends the option of autologous breast reconstruction to women unsuited for major reconstructive procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Syringe Suction Yields Greater Adipocyte Viability for Fat Grafting: Fact or Fiction?

ABSTRACT

Autologous fat grafting is a technique that can be used for cosmetic and reconstructive indications such as oncologic defects, aging, trauma, and congenital malformations. However, there is no standardized technique, and one of the main challenges is the unpredictable rate of fat resorption. When using fat grafting, it is crucial to understand the different factors that contribute to adipocyte viability. A literature search, using PubMed, was conducted in 2022 with variations of the terms "autologous fat grafting," "fat harvesting," "fat processing," and "fat injection." Articles in the English language that presented original data about different factors that may affect adipocyte viability for fat grafting were included in this review. Syringe suction harvests (lower pressures), compared with other methods with higher pressures, were found to have increased adipocyte counts and viability, but this did not translate clinically during in vivo studies. The studies have shown that, despite our efforts in optimizing fat harvest, processing, and injection, no statistical or clinical differences have been found. Additional studies are still needed to determine a universal protocol for optimal fat graft survival.

Stem Cell-Enriched Fat Grafts Versus Autologous Fat Grafts for Facial Reconstruction: A Systematic Review and Meta-analysis

OBJECTIVE

The aim of the study is to compare the outcomes of stem cell-enrichment fat grafting versus routine fat grafting for facial reconstruction purposes.

METHODS

A systematic review and meta-analysis were performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses Guidelines and a search of electronic information was conducted to identify all randomized controlled trials, case control studies, and cohort studies comparing the outcomes of stem cell enrichment fat grafting versus routine fat grafting for facial reconstruction purposes. Volume retention and infection rate were primary outcome measures. Secondary outcome measures included patient satisfaction postsurgery, redness and swelling, fat necrosis, cysts, as well as operation time. Fixed and random effects modeling was used for the analysis.

RESULTS

Eight studies enrolling 275 subjects were selected. There was a significant difference between the stem cell enrichment fat grafting and routine grafting groups in terms of mean volume retention (standardized mean difference, 2.49; P < 0.00001). However, there was no significant difference between the 2 groups in the rate of infection (odds ratio, 0.36; P = 0.30). For all secondary outcomes, the intervention group had similar results compared with the control group except for the operation time, which was shorter in the latter.

CONCLUSIONS

Stem cell-enriched fat grafting is a superior option when compared with the routine fat grafting for facial reconstruction surgery because it improves the mean volume retention and does not worsen patient satisfaction and surgical complications.

Current Fat Grafting Practices and Preferences: A Survey from Members of ISPRES

Fat grafting has established its niche in a wide spectrum of aesthetic and reconstructive procedures. A consensus-based method of harvest, processing, enrichment, injection, and assessment is lacking, despite the rising trends in its application. We conducted a survey among plastic surgeons to evaluate and identify trends of fat grafting practices.

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.

Evaluation of word embedding models to extract and predict surgical data in breast cancer

Background

Decisions in healthcare usually rely on the goodness and completeness of data that could be coupled with heuristics to improve the decision process itself. However, this is often an incomplete process. Structured interviews denominated Delphi surveys investigate experts' opinions and solve by consensus complex matters like those underlying surgical decision-making. Natural Language Processing (NLP) is a field of study that combines computer science, artificial intelligence, and linguistics. NLP can then be used as a valuable help in building a correct context in surgical data, contributing to the amelioration of surgical decision-making.

Results

We applied NLP coupled with machine learning approaches to predict the context (words) owning high accuracy from the words nearest to Delphi surveys, used as input.

Conclusions

The proposed methodology has increased the usefulness of Delphi surveys favoring the extraction of keywords that can represent a specific clinical context. It permits the characterization of the clinical context suggesting words for the evaluation process of the data.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12859-022-05038-6.

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.

Fat Grafting With Expanded Adipose-Derived Stromal Cells for Breast Augmentation: A Randomized Controlled Trial

BACKGROUND

The main challenge with fat grafting is loss of some of the graft to postsurgery resorption. Previous studies suggest that adipose-derived stromal cells (ASCs) can improve the volume retention of fat grafts but there is a lack of randomized trials to support the use of ASCs in clinical practice.

OBJECTIVES

This trial aimed to investigate whether ASCs improve fat graft volume retention in patients undergoing breast augmentation with lipofilling.

METHODS

This was a double-blind, randomized controlled trial of breast augmentation with ASC-enriched fat grafting. Healthy women aged 30 to 45 years were enrolled. First, the participants underwent liposuction to obtain fat for culture expansion of ASCs. Then, the participants were randomly assigned to undergo a 300- to 350-mL breast augmentation with ASC-enriched fat grafting (10 × 106 ASCs/mL fat graft) to 1 of their breasts and placebo-enriched fat grafting of identical volume to the contralateral breast. The primary outcome was fat graft volume retention after a 1-year follow-up measured with MRI. The trial is registered at www.clinicaltrialsregister.eu (EudraCT-2014-000510-59).

RESULTS

Ten participants were included in the trial; all completed the treatment and follow-up. No serious adverse events occurred. Fat graft volume retention after 1 year was 54.0% (95% CI, 30.4%-77.6%) in the breasts treated with ASC-enriched fat grafting (n = 10) and 55.9% (95% CI, 28.9%-82.9%) in the contralateral breasts treated with placebo-enriched fat grafting (n = 10) (P = 0.566).

CONCLUSIONS

The findings of this trial do not support that ASC-enriched fat grafting is superior to standard fat grafting for breast augmentation.

LEVEL OF EVIDENCE: 2

Intercostal Artery Perforator Flap for Salvage Breast Reconstruction with Exposed Breast Implants

Multiple techniques have been described for breast reconstruction surgery after breast implant exposure; breast implant removal and delayed breast reconstruction is the procedure of choice. However, in some mild exposures and infections, we propose an alternative treatment.

Methods

This is a case series of a 14-year study in 16 female patients with mild exposure of a breast implant after breast reconstruction surgery. Salvage surgery was performed on these cases. The defects were between 1 and 6 cm, with a median size of 3.9 × 2.9 cm. Eighteen intercostal artery perforator flaps were used with an island of skin from the inframammary fold; 83.3% were anterior intercostal artery perforator flaps' and 16.7% were lateral intercostal artery perforator flaps.

Results

Thirteen of the 16 patients presented infection (81.25%). There was no necrosis of any flap, and the success rate of salvage surgery was 62.5% of all patients. The success of surgery was 53.8% in patients with breast infection and 100% in patients without infection. Seven patients received chemotherapy and radiotherapy, six received only chemotherapy, and nine patients received only radiotherapy. Five of the six patients whose salvage surgery failed were treated with radiotherapy.

Conclusion

This technique can be used as an alternative when there is exposure of the implant' even in cases with a mild breast infection and in patients undergoing radiotherapy and chemotherapy.

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.

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.

Correction of temporal hollowing after pterional craniotomy by autologous fat grafting. A single-center experience

OBJECTIVE

Aesthetic complications following neurosurgical procedures impact patient quality of life and self-perception. Postoperative temporal hollowing is frequently seen after temporal craniotomy, resulting mainly from atrophy of the temporal muscle. Autologous fat grafting is a tailorable method to correct such approach-related sequelae. We herein present our clinical patient series and discuss pearls and pitfalls of this method.

METHODS

In this retrospective single-center study, correction of postoperative temporal hollowing using autologous fat grafting was performed in 16 patients. Temporal tissue thickness ratio was measured using magnetic resonance tomography images to visualize the graft. Patients, plastic surgeons and neurosurgeons evaluated the results independently using the herein presented scale.

RESULTS

The mean interval between the neurosurgical procedure and fat grafting was 62 months. A mean volume of 11.5 ml autologous fat was injected in an average of 2.5 sessions after initial rigotomy. Temporal tissue thickness was significantly augmented at a mean of 2.2 years after the operation (mean 0.71 ± 0.25, range 0.43-1.1; p=0.0214) as compared to the preoperative finding (mean 0.48 ± 0.1, range 0.32-0.6). Patients were more satisfied with the results than were surgeons, reflecting the significant impact of the deformity on patient self-esteem.

CONCLUSIONS

Autologous fat grafting is a valuable method for correcting postoperative temporal hollowing that provides stable results, high patient and surgeon satisfaction and can be tailored to the patient's individual needs. It should not be considered a merely aesthetic operation, but an important rehabilitation step towards restoring the patient's quality of life.

Autologous Fat Grafting to the Breast: An Educational Review

Autologous fat grafting (AFG) is a technique that is increasingly utilized in breast cosmetic and reconstructive surgery. In this procedure, fat is aspirated by liposuction from one area of the body and injected into the breast. The procedure and process of AFG has evolved over the last few decades, leading to more widespread use, though there is no standard method. Autologous fat grafting is generally considered a safe procedure but may result in higher utilization of diagnostic imaging due to development of palpable lumps related to fat necrosis. Imaging findings depend on surgical technique but typically include bilateral, symmetric, retromammary oil cysts and scattered dystrophic and/or coarse calcifications when AFG is used for primary breast augmentation. More focal findings occur when AFG is used to improve specific areas of cosmetic deformity, scarring, or pain following breast cancer surgery. As with any cause of fat necrosis, imaging features tend to appear more benign over time, with development of rim calcifications associated with oil cysts and a shift in echogenicity of oil cyst contents on ultrasound towards anechoic in some cases. This article reviews the AFG procedure, uses, complications, and imaging findings.

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.

Optimizing Surgical Outcomes with Small-Volume Silicone Implants Associated with Autogenous Fat Grafting in Primary and Revision Breast Augmentation Surgery: Soft Weight Hybrid (SWEH) Concept

BACKGROUND

Simultaneous association of autologous fat grafting (AFG) with silicone implants, defined as a hybrid procedure, has been proposed for breast augmentation (BA). In some patients, larger-volume implants may result in larger incisions, with long-term effects including implant palpability, soft tissue atrophy, and secondary ptosis. Some patients do not want large volume implants, or have insufficient soft tissue coverage. Recent improvements in AFG have led to new surgical options in BA for addressing these cases.

OBJECTIVES

This study combines AFG in BA using small-volume implants, known as the SWEH (soft weight hybrid) approach, and evaluates aesthetic advantages and outcomes following primary/secondary BA.

METHODS

25 patients (50 breasts) underwent SWEH procedures; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant and patients refused large-volume implants. Three-dimensional images were obtained using a Divina 3D scanner system (AX3 Technologies, Miami, USA) to assess breast volume (BV) and intermammary distance (IMD) during follow-up.

RESULTS

Mean patient age was 29.3 years (range: 21-42) and mean body mass index was 19.3 kg/m² (15.3-27.2). The most common implant (SmoothSilk surface Round/Ergonomix style) volume was 180 cc (175-215), and patients received a mean volume of 125 cc of fat (89-168)/breast in the subcutaneous tissue. Preoperative average BV measurements were 236.85 cc (170-335). At 3 and 12 months post-procedure, the average BV values were 488.82 and 478.73cc, respectively (p=0.475). The average preoperative IMD was 31.76 mm (range, 22-43); at 3 and 12 months post-procedure, the average IMD was 20.47 and 20.94 mm, respectively (p=0.61). Postoperative complications included subcutaneous banding in the axilla (n = 1; 4%) and hypertrophic scarring (n = 1; 4%). Breast imaging exams were performed; in 2 breasts (8%) localized oil cysts were observed; no cases of suspicious calcifications, fat necrosis, or lumps were seen. Fat retention rate (1 year) was calculated by the difference between the BV expected with 100% fat intake and the real BV observed. In our sample we observed an average of 72.7 (range: 69.2-77.3, SD: 2.63) and 76.7 (range: 72.3-79.9, SD: 2.18) percent of fat intake on the right and the left breast respectively. No rippling, implant malposition, or infection was observed during a mean follow-up of 22 months (6-40).

CONCLUSIONS

SWEH is a useful surgical alternative that combines the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of larger-volume implants. The association of small-volume gel implants and smaller scars can yield satisfactory aesthetic outcomes.

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 http://www.springer.com/00266 .

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.

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 .

Prolonged antibiotic prophylaxis in tissue reconstruction using autologous fat grafting: Is there a benefit for wound healing?

Fat grafting is a well‐established method in plastic surgery. Despite many technical advances, standardised recommendations for the use of prophylactic antibiotics in fat grafting are not available. This retrospective multicentre study aims to analyse the use of prophylactic antibiotics in fat grafting and to compare complication rates for different protocols. A retrospective medical chart review of 340 patients treated with fat grafting of the breast from January 2007 to March 2019 was performed in three plastic surgery centres. Complications, outcomes, and antibiotic regimes were analysed. The Clavien‐Dindo classification was applied. All patients received perioperative antibiotic prophylaxis: 33.8% (n = 115) were treated with a single shot (group 1), 66.2% (n = 225) received a prolonged antibiotic scheme (group 2). There was no significant difference in the number of sessions (P = .475). The overall complication rate was 21.6% (n = 75), including graft resorption, fat necrosis, infection, and wound healing problems. Complication rates were not significantly different between groups. Risk factors for elevated complication rates in this specific patient group are smoking, chemotherapy, and irradiation therapy. The complication rate for lipografting of the breast is low, and it is not correlated to the antibiotic protocol. The use of prolonged prophylactic antibiotics does not lower the complication rate.

Review of Quantitative Imaging for Objective Assessment of Fat Grafting Outcomes in Breast Surgery

This article presents a comprehensive review of the use of quantitative measurements based on breast images to assess fat retention, breast aesthetics, and fat necrosis after autologous fat grafting. Breast volume measured from MRI and 3-dimensional surface images is widely used as a measure of fat retention. Breast aesthetics are assessed from a combination of anthropometric (distance and contour) measurements on breast surface images. Examination of radiologic images (ultrasonography, mammography, and MRI) is utilized to assess fat necrosis. The article discusses implementation guidelines for objective outcome assessment to support robust quantification and enable investigations of fat grafting efficacy. Level of Evidence: 4.

Subfascial Ergonomic Axillary Hybrid (SEAH) Breast Augmentation: A Surgical Approach Combining the Advantages of Incision, Pocket, Silicone Gel, and Fat Grafting in Primary and Revision Breast Augmentation Surgery

BACKGROUND

Simultaneous application of the axillary approach (AA) with the subfascial pocket (SF) has been proposed for breast augmentation (BA) surgery. New silicone implant technology and recent improvements in autologous fat grafting (AFG) have ushered in a new era for BA.

OBJECTIVES

The aim of this study was to present the combined subfascial ergonomic axillary hybrid (SEAH) method and evaluate its aesthetic benefits after primary/secondary BA.

METHODS

In total, 42 patients (84 breasts) underwent BA with the SEAH technique; this approach was indicated when the overlying tissue was insufficient to adequately cover the implant.

RESULTS

Mean patient age was 34.6 years (range, 28-56 years), mean BMI was 18.8 kg/m2 (range, 14.4-26.1 kg/m2). The most common implant (Motiva SmoothSilk surface Ergonomix style) volume was 255 cc (range, 175-355 cc), patients received a mean fat volume of 96 mL (range, 60-145 mL) per breast in the subcutaneous tissue. The average lower pole stretch value was 40.5% (21.75 mm) and 13.1% (9.9 mm) for preoperative to 10 days postprocedure and 10 days to 18 months postprocedure, respectively. Postoperative complications included subcutaneous banding in the axilla (n = 3, 7.1%), small wound dehiscence (n = 1, 2.3%), and hypertrophic scarring (n = 1, 2.3%). No rippling, implant malposition, infection, or fat necrosis was observed during a mean follow-up of 18 months (range, 6-32 months).

CONCLUSIONS

SEAH is a useful and versatile technique combining the benefits of AFG and implant-based augmentation, particularly with regard to soft tissue coverage, and avoids the limitations of the submuscular position. The combination of ergonomic gel implants and a SF pocket can yield satisfactory aesthetic outcomes.

LEVEL OF EVIDENCE: 4

Impact of Fat Graft Thickness and Harvesting Technique on Adipocyte Viability in a New Porcine Experimental Model: An Immunohistochemical Analysis

BACKGROUND

Autologous fat grafting (AFG) has been employed in surgical practice as a filling method. However, controversies remain on the specifics of this technique. So far, few relevant experimental large animal studies have objectively assessed factors related to AFG integration.

OBJECTIVES

This study utilized an experimental, medium-sized animal model to compare the feasibility of AFG collected employing 2 different techniques with instruments of distinct thicknesses.

METHODS

Twenty minipigs (Sus scropha domesticus) were subjected to AFG harvesting via en bloc resection utilizing 3- (Group I) and 5-mm-diameter (Group II) round punch blades (PBs) and liposuction (LS) with 3- (Group III) and 5-mm-diameter cannulas (Group IV). Both samples were grafted intramuscularly (biceps femoralis). Hematoxylin and eosin staining was employed to identify intact adipocytes, fat necrosis, fibrosis, inflammation, and oil cysts. Immunohistochemical staining (perilipin-A, tumor necrosis factor alfa, and cluster of differentiation number 31) was utilized to quantify the feasibility of adipocytes, tissue necrosis, and neoangiogenesis, respectively.

RESULTS

Hematoxylin and eosin analysis showed that fat necrosis and histiocyte presence were significantly lower in the AFG harvested utilizing a PB than in LS. For perilipin-A, a statistical difference was observed between subgroups I and III (P = 0.001) and I and IV (P = 0.004). Instrument diameter had no effect on graft integration in comparisons between groups II and III (P = 0.059) and II and IV (P = 0.132).

CONCLUSIONS

In this experimental study, fat collected utilizing a PB demonstrated higher adipocyte viability than fat collected with LS. The diameter of the collection instruments, whether PB or LS, had no effect on graft integration.

Large-Volume Autologous Fat Grafting to the Breast

Autologous fat grafting in the setting of breast augmentation and reconstruction has become globally accepted and routinely performed. There is general consensus that small-volume grafting is reproducible and predictable; however, large-volume fat grafting (>100 mL) is less predictable and is not as commonly performed. The aim of this article was to review outcomes following large-volume and megavolume fat grafting in the setting of breast augmentation and reconstruction. Level of Evidence: 4.

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.