Fat grafting in autologous breast reconstruction: applications, outcomes, safety, and complications
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Abstract
Autologous fat grafting is an important surgical technique in aesthetic and reconstructive procedures. Fat grafting for breast reconstruction is now an established procedure for adding volume and improving cutaneous pliability; it can be used independently to replace more invasive flap procedures or implants, or as an adjunct for smaller volume supplementation. The breadth of applications in the breast necessitates diversity in technique and approach, and while there is no universally agreed-upon protocol, basic principles have guided the evolution of some commonly adopted tenets. Broadly, fat grafting outcomes are highly favorable but dependent on patient and procedure factors, requiring learned patient selection and expertise in recipient site assessment. Common complications from fat grafting, such as fat necrosis and the development of nodules, are particularly troublesome for post-oncologic patients, requiring considerable pre-surgical consultation for patient education and managing expectations. In addition to volume and contour augmentation, fat grafting has additional beneficial effects that have recently drawn increased attention including pain reduction from implant capsular contracture or post-mastectomy pain syndrome, improved skin quality and reduced fibrosis following radiation, and possible
Keywords
INTRODUCTION
Reconstruction is a critical component of post-oncologic care for breast cancer survivors, and thus, reconstructive procedures connected with mastectomy are protected by United States federal law by the Women’s Health and Cancer Rights Act of 1998 (WHCRA)[1]. The overall goal of breast reconstruction is to achieve a better quality of life and body image, higher self-esteem and sexuality, and overall psychological well-being[2]. Towards these goals, immediate reconstruction has been found to reduce psychiatric morbidity and body stigma in comparison to delayed reconstruction[3,4]. Methods to optimize outcomes are constantly evolving to address physical and psychological challenges associated with different types of reconstructive procedures to facilitate survivors’ acceptance of oncologic care and avoid long-term negative psychological effects[5-7].
Adipose tissue (fat) is a biocompatible and readily available filler with beneficial biologic effects not observed with inert biomaterials. Indications for autologous fat grafting in the breast are rapidly expanding and currently include deformity correction after mastectomy, augmentation, lumpectomy, mastopexy, reduction mammoplasty, and implant reconstruction[8-11]. While initially used primarily as an adjunct procedure to other reconstructive approaches, including implants or muscle flaps, the fat grafting technique has evolved to inject increasingly larger volumes and is now also used for primary reconstruction[12,13]. The benefits of using fat grafting for reconstruction include reduced morbidity compared to more invasive procedures with similar outcomes[14]. In this review, current applications of fat grafting in breast reconstruction will be described with indications, outcomes, and possible complications, along with patient selection criteria, preoperative assessment, variables that affect graft survival, possible challenges, and techniques developed to overcome these challenges in comparison with conventional reconstruction methods.
FAT GRAFTING SECONDARY TO TRADITIONAL RECONSTRUCTION
Conventional methods of breast reconstruction include implants/prosthetics, autologous flaps, or hybrid flaps with an implant. The choice between reconstruction approaches is often based on several factors, including the patient’s age, overall health condition, body type, lifestyle, breast size, amount of tissue available for reconstruction, patient’s willingness to go through more than one surgery, and recovery time. Other medical or surgical factors used to determine the choice of reconstruction include the extent of oncologic surgery, the further need for post-mastectomy chemotherapy or irradiation, and whether reconstruction is needed for one or both breasts. Additionally, insurance coverage and financial constraints may be considered[15-20].
Implant-based reconstruction
Breast implants remain the most common approach to breast reconstruction according to the American Society of Plastic Surgeons (ASPS) report[21], likely due to the less invasive nature of the surgery and reduced recovery time compared to flap-based reconstruction. Out of the 137,808 breast reconstructions reported by ASPS in 2020, over 103,000 were implant-based, either exclusively or with a tissue expander. In implant-based reconstruction, the implant is placed subpectoral or pre-pectoral and is done either in a single procedure or as a two-staged approach in which a tissue expander is placed immediately and then subsequently exchanged with an implant in a second procedure[22,23].
Drawbacks of implant reconstruction include the development of contracture, rippling (especially in sub-glandular reconstruction and thin patients) and/or undesirable physical appearances. For these reasons, surgeons have evolved implant-based surgeries to include autologous fat grafting, either in one setting or as a delayed surgical procedure, as an adjunct for improving contouring and correcting residual deformities. In the two-staged approach, delayed fat grafting is performed to reduce irregularities or implant delineations which may result from the implant folding over time[9,11,23-25]. Studies have shown high levels of patient satisfaction and low complication rates with this technique[26-28]. Fat grafting can effectively improve the overall breast contour and achieve a more natural-looking shape[29,30]. Delayed grafting is often favored as the recipient tissue bed becomes more vascularized with time and yields increased graft retention. Alternatively, pre-pectoral fat grafting may be performed before implant insertion to increase skin quality and flexibility, improve vascularization, and achieve better overall aesthetic outcomes[24,25,31,32]. Sforza and Spear (2021) proposed that the future of hybrid procedures should include creating a concept for hybrid breast augmentation surgery that provides reproducibility, predictability, and better surgical outcomes based on a safe 3D algorithm[33].
While implant reconstruction is an easier surgery in regard to the required surgical technique and patient recovery, there are some drawbacks. Challenges of implant reconstruction include a high early and long-term failure rate, especially when used following radiation therapy. As it is not always possible to address implant failure or unnatural feel with adjunct fat grafting, many patients opt for flap-based reconstruction[25]. Further, autologous reconstruction can be more cost-effective in the long term compared to implants when considering follow-up health care use required to address adverse events.
Reconstruction with autologous flaps
Flap-based reconstruction is a versatile, reliable, and autologous approach for breast reconstruction and may utilize pedicled flaps such as latissimus dorsi (LD) flap, transverse rectus abdominis (TRAM) flap, thoracodorsal artery perforator (TDAP) flap, or free flaps such as free TRAM, free muscle-sparing TRAM, the deep inferior epigastric perforator (DIEP) flap, or superficial inferior epigastric artery (SIEA) flap. Other rarely used free flaps are lumbar artery perforator (LAP) flap, Gluteal artery perforator (GAP) free flap, Upper gracilis flap (either transverse TUG, vertical VUP, or diagonal DUG), profunda artery perforator (PAP) flap, and lateral thigh perforator (LTP) flap[34]. While implant-based reconstruction requires a shorter operative time, autologous flap-based reconstruction such as latissimus dorsi (LD), transverse rectus abdominis (TRAM), and deep inferior epigastric perforator (DIEP) flaps often yield more satisfactory results for patients[35-39]. Sinna et al. and Bennet et al. reported flap-based reconstruction to provide higher satisfaction and psychological and sexual well-being than implant-based reconstruction[40,41].
Pedicled flaps are most useful in irradiated breast or secondary salvage operations in case of autologous free flap failure. Fat grafting may be used as an adjunct to flap procedures to augment the overall volume and improve contour deformities, minimizing rippling and dynamic distortion[23,40,42-44]. It is relatively common to use fat grafting for secondary procedures after free flaps including PAP and DIEP flaps. Fat grafting may be performed either in conjunction with the flap as a single procedure or as a secondary revision to avoid damaging the flaps and/or circumventing an unfavorable recipient site[45]. Fat grafting with flap reconstruction has also been noted to have beneficial biologic effects in addition to correcting contour deformities, including improvement of skin quality after mastectomy and radiotherapy[46-49].
LD flaps
The LD flap is a pedicled flap and is one of the best options for immediate or delayed breast reconstruction. While the LD is relatively easy to harvest compared to other donor tissues, it is limited by a relatively small tissue volume provided by the flap. One approach to achieve larger volumes is a more aggressive extended LD flap technique which involves harvesting the subcutaneous tissue with the skin paddle, though this carries a higher risk of seroma, contour deformities, and lumbar hernia and is restricted to patients with higher BMI[50-54]. Therefore, LD flaps often require augmentation with an implant to achieve satisfactory aesthetic outcomes[55,56]. Despite its widespread use, the risk associated with implant-based reconstruction after LD flap is relatively high, including capsular contracture, implant displacement and rupture, infection, and the possibility of repeating the procedure to exchange the implant after its expected end-of lifetime[56,57].
Because of the high vascularity of LD flaps[58], they are well suited for adjunct fat grafting to improve the resulting appearance and symmetry [9,49,59,60]. Volumes reported in several studies ranged between 90.5-425 mL[51,56,61,62]. The timing of fat grafting with regard to flap procedures does not appear to affect flap survival, as Zhu et al. showed that all flaps survived regardless of the timing of grafting with no fat-grafting-related complications except for one patient that had undergone radiotherapy and needed additional fat grafting[51,63]. Further, Santanelli di Pompeo et al. demonstrated that immediate intraoperative fat grafting with LD flap surgery was successful with no effect on the outcome or complications and offered direct visualization of fat injection to avoid flap injury[58]. When used in delayed grafting, fat is grafted into all possible recipient sites, including the LD skin paddle, LD muscle caudal to skin paddle, pectoralis major muscle, serratus muscles, mastectomy skin flaps, and thoracoabdominal advancement flaps. In immediate reconstruction, fat grafting and LD flaps may be used after tumor removal with fat injected only into the LD skin paddle and the LD muscle caudal to the skin paddle or after prophylactic mastectomy with fat grafting into the previously mentioned sites as well as the pectoralis major, serratus muscles, and the non-undermined portion of the mastectomy skin flaps. Thus, adjunct fat grafting for LD flaps is a favorable alternative to implant-based reconstruction with fewer complications and is expected to minimize radiation-induced tissue damage[51]. The determination of the relative superiority of one flap over another, when considering various comparator variables, is inherently subjective in nature. The ultimate decision on flap choice can be made on a more individualized basis based on patient and surgeon preference and available tissue donor sites[51].
Transverse rectus abdominis muscle (TRAM) flaps
Originally introduced by Dr. Carl R. Hartrampf to reconstruct the breast using part of the transverse rectus abdominis muscle either pedicled or as a free flap, TRAM flaps often provide larger volume than LD. Alternatively, the DIEP flap spares the abdominal muscle and uses only the skin, fat, and blood vessels. Ideal candidates for TRAM flaps are non-smoking patients that have undergone a single or double mastectomy and have enough excess tissue to reconstruct a whole breast in addition to the general criteria of flap reconstruction including no comorbidities and good overall health condition. A limitation of TRAM flaps is the development of contour irregularities, mostly the superior portion of the breast, that can be corrected with immediate or delayed fat grafting. Because mammary vessels, the dominant vascular pedicle to TRAM flaps may incur trauma during flap harvest, it is generally advised to graft smaller volumes of fat than in double-pedicled or free TRAM flaps, which likely have enhanced flap vascularity and perhaps superior graft survival[64,65].
Challenges inherent to adjunct fat grafting use
Implant and flap-based reconstruction with fat grafting can be challenging because of the unpredictability of fat retention and the possible need for multiple sessions to achieve satisfactory results[6,11,59]. Additional challenges include volume limitations in the amount injected in a healthy chest wall or previously irradiated breast[8]. Though fat grafting has been used for years, researchers and clinicians have yet to come together on an evidence-based, standardized protocol for its use, the steps of the procedure, or a measure of its outcome[66]. Therefore, a variety of techniques and approaches have been used for every step of the procedure, from donor and recipient site preparation, harvesting and processing to reinjection and follow-up procedures. However, most plastic surgeons follow Coleman’s principles in which fat is first concentrated with centrifugation and then injected in small parcels using multiple passes[67,68].
Patient selection
Candidates for fat grafting with breast reconstruction are selected depending on the patient’s acceptance of possible multiple surgeries, the availability of satisfactory donor sites, and the patient’s physical and psychological health condition[48]. It is not favorable if the patient is a smoker or belongs to a high-risk group, including diabetic, obese, and of advanced age[56,69]. Throughout the preoperative assessment, gauging the patient’s mindset and expectations of fat grafting is crucial to outcome success and the patient’s satisfaction. Patients should be informed of the extent of the procedure and possible outcomes to prepare them psychologically for the surgical journey and avoid early disappointment if not well-informed. For example, for some patients, the first fat grafting session does not yield significant volumization and is used to prepare the skin of the recipient site by increasing pliability. Thus, graft resorption is to be expected[13]. To aid in this process, photographs of both donor and recipient sites from different angles can be used to provide a blueprint for both the surgeon and the patient to track the changes and compare the preoperative outlook with the postoperative outcome.
Safety is another important issue to discuss with the patient to eliminate any misunderstanding and explain the frequency of breast imaging needed after the surgery in case of post-cancer reconstruction and the possibility of recurrence and its relation to fat grafting[9,49,70].
TOTAL AUTOLOGOUS BREAST RECONSTRUCTION
Recently, fat grafting has been used independently for primary augmentation, total breast reconstruction, and post-implant replacement, making it an increasingly accepted alternative to the more invasive approaches, especially in small to moderate-volume breasts[47,71-73]. Despite the aforementioned fat grafting drawbacks, using autologous tissue may be preferable to prosthetics for many patients as it does not have implant-related risks and gives a more natural look and feel in comparison[13,46,47,60,74-76]. High satisfaction rates have been described by Dayal, Bhatia, and Hsu, with over 86.5% of patients reported to have either good or very good results judged by an independent panel of surgeons with a mean follow-up of 12 months[47]. Similarly, Groen et al. demonstrated that 92% of patients and 89% of surgeons were satisfied with the results. Finally, fat grafting for breast reconstruction has been linked to psychosocial well-being and improved sexual satisfaction[41,77,78].
Total breast reconstruction with fat grafting is recommended for women requiring small to moderate volume augmentation, such as breast-conserving mastectomy (lumpectomy) to fill contour defects[9,46,48,60]. It is also recommended to minimize significant asymmetry and to improve cleavage appearance by adjusting intermammary distance[9]. Along with its application in congenital anomalies, including tuberous breast deformity and Poland syndrome, fat grafting is used to correct breast hypoplasia and to fill the sub-clavicular and anterior axillary fold defects[48,70,79]. In patients desiring removal of their implants and in cases of implant complications, including malposition, rupture, pain, asymmetry, size change, and capsular contracture, fat grafting is an option to restore lost volume[64].
The outcome of total breast reconstruction with fat grafting can often be better than conventional methods; fat is autologous and readily available, and harvesting and injecting are easily performed[13,75]. The hospital stay in fat grafting alone without any other procedures is often short and the patient is discharged sooner. Ecchymosis and edema are expected in the breast or donor site that usually subsides within 3 weeks after surgery. The long-term result of the operation is most accurately assessed starting 3-6 months post-surgery up to a year to assess the extent of resorption[80].
Reconstruction surgical timing and irradiation considerations
Aside from primary reconstruction in aesthetic cases and congenital anomalies, there is no standard timeline for reconstructive fat grafting after primary surgical care. Traditionally, in cases of breast cancer, fat grafting is performed several months after primary reconstruction at the end of oncologic treatment[40,43,44,51]. Radiation therapy following lumpectomy is believed to adversely affect fat graft survival, making the graft more susceptible to ischemia, fibrosis, and necrosis; thus, fat grafting is delayed in these instances until the completion of oncologic treatment[81]. Alternatively, fat grafting used on irradiated expanders is believed to reduce ulceration and implant exposure[82]. When fat grafting is used after the removal of an implant, the best outcomes are achieved when grafting is performed immediately to take advantage of tissue laxity[23].
Safety and complications
The main drawback of the fat grafting procedure is unpredictable long-term graft survival and the lengthy process potentially requiring several surgeries with 3 months intervals in between[47]. Furthermore, as fat grafting is recommended for those with smaller breast sizes, these patients often do not have enough excess donor material for multiple harvesting requirements. In contrast, those with abundant fat reserves tend to have larger breast sizes that present difficulty in achieving symmetry[13,80]. Finally, weight fluctuation immediately prior to or during graft integration periods has been noted to adversely affects outcomes[8,80].
When large volume replacement is necessary, one session of fat grafting is typically not favorable as boluses of avascular fat lead to central necrosis, adipocyte lysis, oil cyst accumulation and calcification. Hence, multiple sessions with moderate injection volumes are needed to achieve the targeted outcome, which may dissuade patients from requiring large-volume replacement[8]. To address this issue, pre-expansion by either external or internal expanders has been suggested[12,83]. However, proposed devices, such as the Brava, are not broadly available commercially, and when available, require arduous patient compliance[84].
Fat grafting complications can be classified as occurring at the donor site, recipient site or systemically. Donor site complications are dependent on the liposuction technique and the surgeon's skill[8], and may include swelling, bruising, dimpling, hematoma, seroma, pain, infection, paresthesia, hypertrophic scarring, and contour irregularities. Injury to the underlying structures due to cannula penetration is possible but rare. Recipient site complications include infection, resorption, ecchymosis, striae, hematoma, fat necrosis, oil cyst formation, calcification, asymmetry, and failure of graft take, along with persistent pain[23,48,70]. Systemic complications are infrequent and include sepsis, septic shock, pneumothorax, fat embolism, and stroke[85].
While overall complications are relatively low, the rates are higher in patients that have had radiotherapy following modified radical mastectomy and skin-sparing mastectomy[23,86]. Smoking is another factor that could cause unexpected complications, and lastly, larger volume grafting in one session is related to a higher rate of complications[87,88].
Understanding the incidence of postoperative complications following breast augmentation with fat grafting could enhance the collaborative decision-making process between patients and healthcare providers in determining whether fat grafting is a preferential alternative to conventional breast implant-based techniques in specific cases. The majority of fat grafting reported complications include asymmetry, skin irregularities, oil cysts, calcifications, palpable cysts, fat necrosis, infection, hematoma, and seroma. The incidence of these complications varied among the studies, with oil cysts and calcifications being the most frequently observed radiologic changes. The formation of oil cysts ranged from 0-83%, with a reported incidence of 6.5% following radiologic analysis. Calcification incidence ranged from 0-80%, with a reported incidence of 4.5% following radiologic analysis. The incidence of fat necrosis varied from 0-10%, with a reported incidence of 1.2% following radiologic analysis. Palpable cysts ranged from 0-15%, with 40%-100% requiring aspiration. The incidences of infection, hematoma, and seroma were under 5%[24,89-91].
There has been an evident concern raised in the literature regarding the possibility that fat grafting could promote cancer recurrence; however, an abundance of clinical evidence has yet to demonstrate any clear statistical correlation between cancer recurrence and autologous fat grafting in the majority of patients[81,92]. Further, the mixed use of implants with fat grafting in reconstructive surgery does not appear to have any impact on cancer recurrence and may reduce implant-associated risks, including fibrosis and capsular contracture[23,93-95]. Similarly, fat grafting used with implants in patients with BRCA mutation undergoing prophylactic mastectomy or in patients who have had implants removed due to breast implant-associated anaplastic large cell lymphoma (ALCL) has not demonstrated any increased risk of tumorigenicity[96-98]. Of note, a 2013 study by Petit et al. showed a higher risk of a local oncologic event in intraepithelial neoplasia patients following lipofilling compared to a matched cohort (59 and 118 patients in each respective group) and thus, fat grafting may need to be avoided in patients belonging to this subgroup[99]. Moreover, there has been significant concern regarding fat necrosis and calcification in the breast and its effects on the accuracy of mammography, particularly in patients who are receiving fat grafting after breast cancer surgery. Multiple studies have addressed the detection of subsequent malignancy in the setting of fat necrosis. One such comprehensive systematic review, which incorporated a cohort of 4,601 patients who underwent breast fat grafting for the purpose of augmentation and reconstruction, was conducted to evaluate the incidence of radiographic abnormalities at 12 months post-procedure. The results of this review revealed that 13% of patients developed radiographic abnormalities, which is comparable to the rate of radiographic abnormalities observed following other procedures involving the breast. Another retrospective analysis of mammography reports of 31 patients who underwent fat grafting was conducted, which revealed the presence of microcalcifications, macrocalcifications, and cysts in postoperative mammograms; however, all lesions were classified as benign according to the Breast Imaging Reporting and Data System II. A comparative analysis of 20 pre- and post-graft mammograms was performed, and no statistically significant difference in breast tissue density or in the Breast Imaging Reporting and Data System II assessment category was observed after fat grafting. Together, these findings provide evidence that fat grafting does not impede mammographic follow-up[75,100,101].
Patient selection
Candidates must be carefully selected depending on their acceptance for multiple surgeries, availability of satisfactory and sufficient donor sites, the patient’s physical and psychological health condition, and no active cancer or recurrence within 6 months of surgery[48]. Fat grafting outcomes are more favorable in a nonirradiated breast after mastectomy, and if the reconstruction involves only one breast rather than two. In instances where fat grafting is used following implant failure, replacement of the failed implant with fat grafting has been proposed as an option for those that cannot tolerate lengthy flap procedures or those who had recurrent prosthetic infections either due to being high-risk patients or comorbidities that make them unfit for anesthesia.[9,23,69].
FAT GRAFTING FOR PAIN REDUCTION
Some of the most current and emerging uses for autologous fat grafts are scar and pain treatment following mastectomy and/or radiation therapy[23,102-105]. Post-mastectomy pain syndrome (PMPS) entails more than just post-surgical pain; it is neuropathic, lasts at least 6 months, occurs at least 50% of the time and presents as dull, burning, and aching sensations involving the chest, axilla, and ipsilateral upper extremity[23,72,88,106-108]. Activities such as movement, straining, overhead activity, and cold weather can exacerbate symptoms and cause further disability, reduced quality of life, and emotional distress. Jung et al. classified PMPS into four categories; phantom breast pain, intercostobrachial neuralgia stemming from intercostobrachial nerve damage, neuroma pain, and other nerve injury pain from surrounding nerves’ damage[60,106,107].
The current leading hypotheses on PMPS etiology include intraoperative nerve damage to any of the primary nerves affected during mastectomy or breast surgeries in general, i.e., the intercostobrachial, medial and lateral pectoral, thoracodorsal, long thoracic, and intercostal nerves[108,109], and subsequent entrapment in cicatricial fibrosis, which may incite continuous nervous excitement. Additional hypotheses include decreased circulation, scarring/fibrosis, and injury to fibroblasts after radiation[60,106,110].
Autologous fat grafting is believed to help with scar remodeling, enhance angiogenesis, reduce nerve entrapment within adhesions, and provide local analgesia by inhibiting the inflammatory response[60,105,106,110]. Several Level I/II clinical studies have shown that fat grafting significantly reduces PMPS-related pain compared to control cohorts[87,105,111-113]. Lisa et al. analyzed patient demographic factors affecting fat grafting clinical efficacy and found no significant association between age, BMI, the menopausal status of patients, time from oncologic surgery to autologous fat grafting and reduction of the Visual Analogue Scale (VAS) values over time[87]. Smoking and axillary dissection were the main factors significantly associated with reduced fat grafting efficacy (respectively, P = 0227 and P = 0066)[87].
There have been very few mechanistic rationales provided as to why fat grafting improves fibrosis; however, the above studies postulated regenerative factors produced by tissue after grafting. This aligns well with preclinical research showing that lipoaspirate particles continue to secrete high concentrations of growth factors such as vascular endothelial growth factor (VEGF), hepatocyte growth factor (HGF) and anti-inflammatory cytokines such as IL-10 in hypoxic environments that occur immediately after graft injection[114-116], which may improve the recipient tissue health. However, significantly more research is needed in this area.
FAT GRAFTING FOR CAPSULAR CONTRACTURE
Despite advancements in biomaterial’s texture and composition, implant-based breast reconstruction remains challenging due to the prevalence of postoperative complications; one of the most common is capsular contracture, especially in patients who have received radiation therapy as part of their cancer treatment[117]. The development of a thin capsule around foreign objects is a normal immune response following implant placement and typically has minimal effects on the appearance or consistency of the operated breast. However, over-activation of the immune response can cause inflammatory cell recruitment and excessive fibrosis, which results in the synthesis of a matrix around the implant. Fibroblast proliferation and organization into structured capsules in proximity to frustrated, overactive phagocytes lead to chronic inflammation and differentiation of fibroblasts into myofibroblasts, inducing contractile scar tissue. Fat grafting purportedly ameliorates capsular contracture through the same mechanism mentioned by reducing nerve entrapment and also helps to improve skin quality and sensation after contracture[49,60,105]. An early preclinical study demonstrated that autologous fat transfer reversed capsule severity following pericapsular injection by promoting neovascularization of adjacent tissue and softening of the capsule[118]. Subsequent research has investigated the underlying mechanisms behind these benefits. A recent in vitro study utilizing adipose-derived stem cells demonstrated secretome-mediated reversal of pro-fibrotic cellular and molecular changes in dysfunctional fibroblasts, and proposed that this is the process by which autologous fat transfer softens and reduces capsular fibrosis[119]. Animal models of capsular contracture have shown that autologous fat transfer during implant placement prevents the formation of capsular contracture by reducing tissue inflammation and decreasing collagen content, density, and fiber alignment of the capsular tissue[117,118].
There is also growing clinical evidence identifying autologous fat transfer's role in reducing the risk of capsular contracture[120]. One study showed that it can be a practical treatment strategy for symptomatic capsular contracture by mitigating fibrotic damage, reducing severity, and alleviating symptoms to the extent that corrective surgery was circumvented[121]. Another showed that autologous fat transfer could prevent the recurrence of capsular contracture when serially administered in severe cases of capsular contracture following implant removal and partial capsulectomy[122].
The benefits of autologous fat transfer are even more pronounced when implant-based breast reconstruction involves patients treated with radiation therapy. It is well-documented that there is an increased risk of capsular contracture in these patients[123,124]. The benefits were documented for the first time in 2009 when a study showed that serial autologous fat transfer could improve outcomes and reduce complications of implant-based breast reconstruction for patients with irradiated breasts[125]. Subsequent studies demonstrated that autologous fat transfer before implant placement can improve healing, increase soft tissue stability, and reduce radiation-related complications[126-128]. When used to treat post-irradiation capsular contracture, autologous fat transfer was able to decrease long-term symptom rates and reduce the need for follow-up surgery[129,130]. Although beneficial in many respects, autologous fat transfer is not without limitations. In one study, it was shown to have no protective effect as a prophylactic agent when used to prevent radiation-induced capsular contracture[131]. Additional research is needed to better understand the value and restrictions of using autologous fat transfer for the prevention and treatment of capsular contracture after implant placement.
RESEARCH ON THE HORIZON
Fat grafting is generally considered a versatile and useful method for creating autologous volume despite the aforementioned challenges regarding unpredictable retention. However, past research on total breast reconstruction with fat grafting lacks a compelling argument to convince most reconstructive surgeons to perform it regularly for breast reconstruction. There exists a need for robust and convincing data to demonstrate the superiority of fat grafting in terms of patient satisfaction. In addition, more studies are needed that address retention, cryopreservation, safety, and efficacy. It is yet to be determined if this evidence alone will encourage this technique. Other factors, such as reimbursement and feasibility, do play an important role. To ease the burden incurred by multiple harvesting procedures, research is underway to evaluate cryopreserved fat for future secondary procedures or use biologic adjuncts to improve primary fat grafting retention.
To date, Level I/II evidence suggests cryopreserved lipoaspirate has fair clinical outcomes, primarily when used for small volumization in the face[132,133]. When used in larger volumes for gluteal augmentation, one case study describes outcomes in a 42-year-old male as satisfactory using abdominal adipose cryopreserved at -20 ˚C for 3 months[134]. Therefore, secondary touch-up procedures in the breast following reconstruction may be feasible. However, significantly more work in procedure standardization is required as others have noted potential clinical risks associated with oil cyst accumulation from reduced tissue viability from storage[135] and lack of validation towards sterility, potentially causing infection such as what occurred in a 22-year-old female who presented with multiple abscesses in her face requiring a year to control[136].
To avoid secondary procedures altogether, a variety of biologics have been admixed with lipoaspirate to improve overall take. To date, the most compelling outcomes have been obtained using culture-expanded adipose stem cells, whereby Kolle et al. obtained mean retention of 80.9% in 10 patients measured by MRI[137,138]. Other Level I/II studies have reported utilizing platelet-rich plasma[139] or stromal vascular fraction[140,141] with lipoaspirate but have been unable to achieve reliably increased retention outcomes in the breast and both increased the incidence of complications and did not decrease the frequency of multiple operations after lipo-transfer[142]. Current clinical data suggests that the addition of adipose stromal cells
Interestingly, studies have been conducted using lipoaspirate washed with Poloxamer 188, or P188 and determined that the copolymer may reduce apoptosis, increase the mass of the fat transplant, improve cell viability and DNA content, and enhance the histological composition of the fat grafts. The investigators hypothesized that P188 copolymer stabilized adipocyte cell membranes to, preventing reabsorption and cell death[144].
CONCLUSION
The surgical approach for breast reconstruction involves many patient-specific factors including anticipated outcomes and patient preference. Fat grafting is, by now, an established part of the surgical armamentarium for improving the final appearance and feel of the breast and can be used successfully as an adjunct to traditional prosthetic/implant or flap-based approaches. With the continuous evolution of the technique, autologous fat grafting is likely to emerge as an acceptable option to provide higher patient satisfaction and improved quality of life.
DECLARATIONS
Authors’ contributionsContributed to review design: De La Cruz C, Kokai L, Shaaban B
Contributed to writing: Shaaban B, Kokai L, Guerrero D, De La Cruz C
Approved the final draft: De La Cruz C, Kokai L
Availability of data and materialsNot applicable.
Financial support and sponsorshipNone.
Conflicts of interestAll authors declared that there are no conflicts of interest.
Ethical approval and consent to participateNot applicable.
Consent for publicationNot applicable.
Copyright© The Author(s) 2023.
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Shaaban, B.; Guerrero, D.; De La Cruz, C.; Kokai, L. Fat grafting in autologous breast reconstruction: applications, outcomes, safety, and complications. Plast. Aesthet. Res. 2023, 10, 12. http://dx.doi.org/10.20517/2347-9264.2022.91
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