ReviewAutologous fat grafting in onco-plastic breast reconstruction: A systematic review on oncological and radiological safety, complications, volume retention and patient/surgeon satisfaction☆
Introduction
Autologous fat grafting (AFG) was first introduced in the 1890s by Neuber and Czerny, who began to transplant fat tissue and lipomas. Since then, interest in the technique waned because of the high reabsorption rates.1 In 1987, AFG was prohibited in breast reconstruction procedures, as its use was found to impede cancer diagnostics as well as possibly stimulate the formation of breast cancer itself.2 After Coleman3, 4 standardized the procedure in 1995 and achieved greater procedure accuracy and good results, further studies led to the 2009 statement by the Fat Graft Task Force of the ASPS that ‘the procedure is not prohibited (due to the lack of evidence) nor recommended, and should only be performed by specialized surgeons’.5 Since then, AFG has been increasingly used in reconstructive breast surgery.
The safety and efficacy of AFG in breast surgery, as well as other indications, are currently of great interest, with several original studies and reviews being published. However, the latter mainly include case reports or small case series, and they generally focus on one or two outcomes. As this technique becomes more widely accepted, more questions arise, as indicated by the editorial piece of Longaker et al.6 Hence, our aim is to present a comprehensive overview of the current evidence on the outcomes of onco-plastic breast reconstruction with the (supplemental) use of AFG and to reveal gaps in the current literature to form a basis for further research.
Specifically, we aim to determine the following:
- 1)
Oncological safety: the frequency of oncological recurrences in relation to the type of malignancy.
- 2)
Radiological safety: the type and frequency of radiological findings and the number of biopsies based on these findings.
- 3)
Complications: the frequency and type of complications in relation to the graft technique used.
- 4)
Fat grafting technique: the number of grafting procedures and the volume of grafted fat.
- 5)
Efficacy: patient/surgeon satisfaction and fat graft retention in relation to adjuvant radiotherapy.
Section snippets
Methods
A systematic review of the literature on AFG in the female breast was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement (www.prisma-statement.org).7 PubMed, Embase.com, Wiley/Cochrane Library and Web of Science were searched from inception (by JG and JCFK) between January 1996 and November 2014. The following terms were used (including synonyms and closely related words) as index terms or free-text words: ‘fat’ or ‘adipocyte’ or
Results
After screening, a total of 44 studies were included (Figure 1).8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 46, 47, 48, 49, 50, 5 Two studies12, 13 described the same group of patients; thus, one of the studies13 was excluded from the analyses, leaving 43 studies. The included studies were published in the period 2005–2014. This included almost equal numbers of retrospective and prospective
Discussion
Summary of evidence.
Conclusions
Presently, nearly all studies on the use of AFG in breast reconstruction after breast cancer are of low evidence level. Yet, these studies indicate that AFG is a promising technique, providing high satisfaction rates. Safety does not seem to be compromised as cancer recurrence rates and complication rates are not increased. Whether AFG interferes with radiological follow-up remains to be seen. Most benign irregularities can be clearly distinguished, but slightly a higher number of biopsies are
Funding
None.
Conflict of interest
None.
Acknowledgements
None.
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Presented in part at: Barcelona Breast Meeting, 11 March 2015: Fresh ideas session: Short presentations on oncoplastic and reconstruction surgery moderator.