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

Efficacy of Exclusive Fat Grafting for Breast Reconstruction: An Updated Systematic Review and Meta-analysis

BACKGROUND

Exclusive fat grafting is an alternative method to implant- or flap- based reconstruction techniques following mastectomies or breast conservation therapies. Its efficacy has been explored before but new data has come to light, resulting in previous results becoming outdated. Concerns have also been raised about the oncological safety of this procedure which must be evaluated alongside the efficacy to gain a comprehensive understanding of the merits of this alternative technique.

METHODS

We queried the PubMed electronic database from its inception until August 2023 for studies evaluating the efficacy and oncological safety of exclusive fat grafting breast reconstruction following cancer-related mastectomy or breast conservation therapy. Results of the analysis were pooled and presented as means or valid proportions. Results of the analysis were pooled using a random-effects model and presented with 95% confidence intervals (95% CIs) where appropriate.

RESULTS

41 studies were included in our analysis. Pooled results show that on average, 1.7 sessions of exclusive fat grafting were required to complete reconstruction in Breast Conservation Therapy (BCT) patients, with an average volume of 114.2 ml being injected. For mastectomy patients with irradiated breasts, 4.7 sessions were needed on average with 556.8 ml being required to complete reconstruction, compared to their non-irradiated Counterparts requiring only 2.6 sessions and 207.2 ml to complete reconstruction. Oncological recurrence events were found in 29/583 non-irradiated mastectomy patients (p = 0.014) and in 41/517 BCT patients (p = 0.301) CONCLUSION: Exclusive fat grafting is an oncologically safe and reasonably efficacious alternative to more common methods of breast reconstruction. More data is needed to fully characterize the oncological safety of this procedure in irradiated and non-irradiated mastectomy patients.

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 .

Volume retention rate after breast autogenous fat grafting and related influencing factors: A systematic review and meta-analysis

The volume retention of breast autologous fat grafting is unpredictable, and the volume retention rate and related influencing factors have not been systematically reviewed. Therefore, this systematic review and meta-analysis aimed at evaluating the volume retention rate and related influencing factors of breast autologous fat grafting, which is for reconstructive or esthetic purposes. Literature search was conducted using the PubMed, Embase, Cochrane Library, and Web of Science databases from inception of study to December 2022. Sensitivity analysis was performed for all outcomes. Begg's test was performed to test publication bias. Subgroup analysis was performed based on population, method of fat preparation, method of volume measurement, number of fat grafting, and injected fat grafting volume. A total of 25 studies were included in this systematic review and meta-analysis. The follow-up time ranged from 3 to 36 months. Results showed that the pooled volume retention rate at the latest follow-up point was 54% [95% confidence interval (CI): 48.5%-59.5%]. Based on the fat preparation methods, the pooled rate was 51.5% (95%CI: 41.5%-61.5%) for centrifugation, which was higher than that for sedimentation [38.7% (95%CI: 30.9%-46.5%)]. In addition, the enrichment of stromal vascular fraction obtained after centrifugation was found to be associated with higher volume retention rate (weighted mean difference: 17.36, 95%CI: 8.84-25.87). Our findings may provide guidance for evaluating the volume retention rate of breast autologous fat grafting in clinical settings. Further studies are needed to verify our findings.

Conversion to Autologous Breast Reconstruction with Latissimus Dorsi and Immediate Fat Grafting in Patients with Previous Implant Failure: An Efficient, Reproducible, and Safe Technique

Introduction  Implant-based breast reconstructions (IBBRs) increased last years despite the growing indications for radiotherapy in the treatment of breast cancer. As a result, complications and reconstructive failures associated to IBBR have increased. Autologous breast reconstruction (ABR) using fat-augmented latissimus dorsi (FALD) has become popular in recent years. Methods  We aimed to evaluate conversion to ABR using latissimus dorsi and immediate fat grafting in 61 cases with IBBR failure. Results  Immediate reconstruction was found significatively related with an increased number of surgeries resulting from IBBR complications ( p  < 0.001). Note that 41% of the cases presented a grade III/IV Baker and Palmer capsular contracture, 29% implant extrusion, and 21% implant infection. Mean survival of the first implant was 16.95 months. ABR process was completed in 47% of cases with a single surgery. Statistically significant differences were observed between this fact and previous IBBR failure due to infection ( p  = 0.03) or extrusion ( p  = 0.01). Mean volume of fat graft was 429.61 mL, mean length of the surgical procedure was 3.17 hours, and the average length of hospital stay after surgery was 2.67 days. Only 3.3% of the cases developed some major complication. None of the cases presented reconstructive failure. Conclusion  FALD is a very safe total ABR technique, an important fact in patients with previous reconstructive failures. The large volume of fat that can be grafted in a single surgery allows the reconstruction of breast in a reasonable size. The reduced length of surgery and hospital stay make the FALD technique an option to consider when an autologous but efficient and safe reconstruction is desired.

[Lipofilling in the management of breast cancer: An update based on a literature review and national and international guidelines]

BACKGROUND

Lipomodelling (LM) is an increasingly used technique to reconstruct or correct an aesthetic defect linked to a loss of substance. In France, the Haute Autorité de santé (HAS) published recommendations in 2015 and 2020 concerning the conditions of use of LM on the treated and contralateral breast. These appear to be inconsistently followed.

METHODS

Twelve members of the Senology Commission of the Collège national des gynécologues-obstétriciens français (French College of Gynecologists and Obstetricians) reviewed the carcinological safety of LM and the clinical and radiological follow-up of patients after breast cancer surgery, based on French and international recommendations and a review of the literature. The bibliographic search was conducted via Medline from 2015 to 2022, selecting articles in French and English and applying PRISMA guidelines.

RESULTS

A total of 14 studies on the oncological safety of LM, 5 studies on follow-up and 7 guidelines were retained. The 14 studies (6 retrospective, 2 prospective and 6 meta-analyses) had heterogeneous inclusion criteria and variable follow-up, ranging from 38 to 120 months. Most have shown no increased risk of locoregional or distant recurrence after LM. A retrospective case-control study (464 LMs and 3100 controls) showed, in patients who had no recurrence at 80 months, a subsequent reduction in recurrence-free survival after LM in cases of luminal A cancer, highlighting the number of lost to follow-up (more than 2/3 of luminal A cancers). About follow-up after LM, the 5 series showed the high frequency after LM of clinical mass and radiological images (in ¼ of cases), most often corresponding to cytosteatonecrosis. Most of the guidelines highlighted the uncertainties concerning oncological safety of LM, due to the lack of prospective data and long-term follow-up.

DISCUSSION AND PERSPECTIVES

The members of the Senology Commission agree with the conclusions of the HAS working group, in particular by advising against LM "without cautionary periods", excessively, or in cases of high risk of relapse, and recommend clear, detailed information to patients before undergoing LM, and the need for postoperative follow-up. The creation of a national registry could address most questions regarding both the oncological safety of this procedure and the modalities of patient follow-up.

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.