Perspectives on fat transfer prior to alloplastic breast reconstruction based on recent published data

Autologous fat transplantation (AFT) has become increasingly common in breast reconstruction to address contour deformities, add volume, and improve skin quality. In the setting of radiotherapy, there is an additional purported benefit of AFT in reversing the deleterious effects of radiodermatitis.

We read with great interest the article “Autologous fat transplantation prior to permanent expander implant breast reconstruction enhances the outcome after two years: a randomized controlled trial”, by Lindegren et al. (1). We commend the authors for performing an important randomized controlled trial of radiated delayed breast reconstruction (DBR) patients comparing two groups: AFT then alloplastic reconstruction (intervention group), versus alloplastic reconstruction alone (control group).

Women who underwent post-mastectomy radiation (PMRT) between the ages of 25–70 years, who were not candidates for flap reconstruction, were included in the study. Among exclusion criteria was a body mass index (BMI) over 30 kg/m², which may limit the generalizability of this study. The first reconstruction surgery (AFT or expander placement) was performed at least one year after prior breast surgery or radiation.

For the intervention, AFT was performed at least once between 2–6 months prior to expander insertion, with the goal of transplanting 100 cc of fat to the reconstruction site. A limitation in this study is variability in fat grafting techniques including fat harvesting, processing, and injection. While the study does not provide detailed information on these aspects, they are crucial for the success of AFT (2-4). It is unclear what metrics the authors used to determine success or failure of a fat grafting session and importantly, how they determined whether more than one fat grafting session was necessary or indicated. Defining the authors’ preferred technique and number of fat grafting sessions prior to expander placement would add to reproducibility of this study’s findings.

Follow-up appointments with the surgeon were carried out at 6-, 12- and 24-months from the expander surgery, and with nurses for expansions and on an as-needed basis. We applaud the 2-year follow up for patients in this study; however, it was unclear from our review of the study the number of patients in each arm per follow-up time-point.

One of the strengths of this study is the study design, including sample size calculation and over-recruitment of patients. However, due to unexpected high losses to follow-up and slowing of recruitment (posited to be due to the increasing popularity of immediate breast reconstruction), the study was ultimately underpowered to detect a difference between the two groups. Although not statistically significant, the results of this study are in favor of AFT in the primary outcomes of complications and reoperations. Notably, there were five patients with capsular contracture (CC) in the control group and only one in the intervention group, suggesting a protective effect from AFT in CC. The study also demonstrated twice as many patients underwent reoperation to perform fat grafting in the control group as compared to the intervention group. In the secondary outcomes, we were most interested to see that patients’ psychosocial well-being and satisfaction with breasts were significantly better at 24-months in the intervention group.

Radiation is an integral part of breast cancer treatment. Postmastectomy radiation can result in radiodermatitis, tissue fibrosis and atrophy; in alloplastic reconstruction this can manifest as increased risk of infection, CC, implant malposition and reconstruction failure (5,6). Delayed tissue effects of radiation may present years later. In DBR, due to long term radiation tissue changes, expanding radiated tissue confers risks of pain, implant exposure, infection, chest wall deformation, or possible rib fracture. Standard methods of reconstruction in radiated chest walls involves recruiting non-radiated tissue with a latissimus dorsi flap combined with expander/implant, or pure autologous reconstruction using a transverse rectus abdominis myocutaneous (TRAM) flap or deep inferior epigastric perforator (DIEP). These flap and hybrid reconstruction options should be discussed with patients as salvage options if tissue expander (TE) fails.

Radiation has evolved over the years with improved delivery systems, patient positioning and dose fractioning (7,8). Many patients present with less noticeable radiation damage than in previous years. Despite these advances, variability in outcomes exist and radiation effects can manifest differently in different patients. In some cases, the atrophy, damage and tightness obviate any treatment options other than the recruitment of healthy vascularized flaps. Our own experience has evolved significantly from the time when radiation was a near absolute contraindication for alloplastic reconstruction. Like the authors of this paper, we regularly perform implant-based techniques in patients with previous radiation. It is, however, crucial to assess each patients’ tissues individually. In cases where there has been intense radiation damage with thin skin flaps that are tightly adherent to a fibrotic muscle, it is wise to prioritize options that bring healthy vascular tissue to the area.

DBR in the setting of PMRT requires novel solutions to optimize reconstruction for a successful outcome. Not all patients are candidates for autologous reconstruction, and many prefer to avoid donor sites and pursue alloplastic reconstruction. TE techniques have been well-described in the literature; recent advances using acellular dermal matrix (ADM) and AFT aim to mitigate some of the damaging effects of radiation on mastectomy tissue in preparation for TE based reconstruction (4,9-11).

ADM has been shown to reduce the rates of CC and, by Seth et al., decrease the risks of complications in the setting of radiation (9,12). In the radiated breast, ADM decreases peri-implant inflammation in ADM-capsule as opposed to native capsule, which may contribute to lower rates of CC and improved overall outcome (10).

Similarly AFT has improved the outcomes in PMRT breast reconstruction through modifying tissue quality (13-15). AFT introduces mesenchymal stem cells to the radiated tissue bed; these cells release growth factors resulting in neovascularization of ischemic tissue and keratinocyte proliferation in wound healing (16,17). In addition to improving reconstruction outcomes, the safety of using AFT stem cells in breast reconstruction has been well-documented, demonstrating no increased risk of locoregional recurrence with the use of AFT (4,18,19).

Our senior author has been performing AFT to prepare tissues for expander reconstruction for over 10 years, with and without ADM. AFT has allowed us to expand the candidates eligible for alloplastic reconstruction through qualitative change to the tissues. Here, we perform AFT in one or several treatments prior to expander placement until desired tissue pliability is achieved. Fat is harvested using standard liposuction techniques at a pressure of 0.5 atmosphere. The fat is collected into a closed system, followed by serial washes with normal saline to remove blood cells, oil from damaged adipocytes and other inflammatory debris. No centrifugation is performed. Fat is placed in 10 cc syringes and injected with a small single hole cannula. The fat is placed subcutaneous in the entire field of radiation. We also attempt to place fat within or deep to the pectoralis muscle. Typically, a total of 100–150 cc is placed with each session. TE insertion is generally performed three months following the last fat grafting session. We aim to place the expander in a pre-pectoral position to avoid lifting the fibrotic muscle. ADM is usually placed as a lining of the skin in the lower pole of the breast. Expansion is guided by tissue compliance and patient comfort. Careful follow-up is critical. If expansion fails to proceed adequately or patient discomfort and tightness is excessive, consideration must be made for conversion to an autogenous option.

In Lindegren et al.’s study, 2 years of follow up is commendable; further studies are required to clarify the longevity of protective effects of AFT and long-term outcomes.

Achieving a successful outcome in breast reconstruction in multifaceted. Ultimately, the success of a reconstruction depends not only on breast mound creation, but also on patient experience and functionality. Being able to create a breast mound through fat grafting, TE placement, and successful expansion may connote successful breast mound creation. However, if this results in a tight, high, painful or asymmetric breast, success has not ultimately been achieved. By incorporating the BREAST-Q in this study, the authors are interested in creating a shared definition of success with their patients. We continue to challenge our own definitions of success in breast reconstruction as we continue to strive for both an acceptable aesthetic and functional result.

We thank the authors of this article for their contribution to the breast reconstruction literature. We congratulate the authors of this article for their successful completion of a randomized controlled trial and for contributing important information that expands the options for women undergoing reconstruction following radiation therapy.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Gland Surgery. The article has undergone external peer review.

Peer Review File: Available at https://gs.amegroups.com/article/view/10.21037/gs-24-408/prf

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://gs.amegroups.com/article/view/10.21037/gs-24-408/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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