'Fat Grafting' as a Third Option for Breast Reconstruction

New data provide reassurance about the safety of autologous fat transfer (AFT) for breast reconstruction following surgery for breast cancer.

AFT — also known as fat grafting — uses fat from another part of the body, often the abdomen, flanks, or thighs. The fat is removed by liposuction, processed, and then injected into the breast.

This technique should now be offered to patients as a third option along with the standard approaches of breast implants and tissue flap reconstruction, say experts commenting on the new data in an editorial published online October 10 in JAMA Surgery.

Roger K. Khouri, MD, of the Miami Breast Center, in Key Biscayne, Florida, and colleagues comment that, "as in much of medicine, there is no one superior option."

However, the editorialists also say that the drawbacks associated with the two standard reconstruction techniques have led many breast cancer patients to opt out of reconstruction entirely.

"Now that AFT has been proven safe and effective, the standard of care should reflect this latest addition," they say, adding that plastic surgeons should present all three options to patients who are to undergo mastectomy.

New Data on AFT

The new data on AFT come from a retrospective study published online October 10 in JAMA Surgery.

Lead author Todor Krastev, MD, of Maastricht University Medical Center, the Netherlands, and colleagues note that AFT has become an invaluable tool for correcting tissue deformities after breast cancer surgery.

However, clinical studies into the oncologic safety of AFT vs conventional breast reconstruction have produced conflicting results, they note.

"Application of AFT in patients with breast cancer has been restricted by two main factors: the fear that it can interfere with breast cancer imaging, and that intentionally placing regenerative cells in a previous tumor bed could increase the risk of locoregional recurrence," the investigators say.

The current study is the first in which there was a 5-year follow-up of patients who underwent AFT, they point out. They note that the study was designed to provide evidence as to whether AFT increases risk for breast cancer recurrence.

For the study, the team used the patient database at the Tergooi Hospital in Hilversum, the Netherlands, to identify 287 patients with breast cancer (300 affected breasts) who received AFT between 2006 and 2014.

Each AFT patient was matched for age, type of oncologic surgery, tumor invasiveness, disease stage, and locoregional, recurrrence-free interval at baseline with 300 breast cancer patients who served as control patients.

The mean age was 48.1 years for patients undergoing AFT and 49.4 years for control patients.

The patients who received AFT were followed for a mean of 9.3 years from the primary oncologic surgery. The control patients were followed for a mean of 8.6 years.

The data were analyzed between 2016 and 2017.

The results show that after 5 years of follow-up, there were eight locoregional recurrences (LRRs) among the 287 women who underwent breast reconstruction with AFT, and 11 LRR events in 300 matched control patients (unadjusted hazard ratio, 0.63; P = .33).

No notable differences in LRR were observed between subgroups with respect to the type of surgery, invasiveness, disease stage, and the presence of triple-negative breast cancer, the authors say.

"The findings of this matched cohort study show no significant differences in the LRR between patients undergoing AFT and control patients after 5-year oncologic follow-up," the authors write. "In line with reported rates from other published matched cohorts, there is no clinical evidence so far to suggest that AFT leads to increased rates of cancer relapse in patients with breast cancer."

The study also showed that AFT was not associated with an increased risk for distant recurrence (hazard ratio [HR], 0.94; P = .85).

In addition, the mortality rate for patients who underwent AFT was significantly lower than for control patients (eight vs 33; HR, 0.20; P < .001). This was particularly true with respect to breast cancer–specific mortality (HR, 0.37; P = .02)

Less Invasive Option

In the accompanying commentary, Khouri and colleagues write that with AFP, a series of minimally invasive autologous fat injections are used to seed a scaffold with cells that grow into a breast mound. "Having patients regrow their lost breasts in situ may well be the most cost-effective, least invasive, and most satisfactory option," they write.

The technique can also be offered to women who have received tissue expanders or implants, because these "act like internal expanders to create the necessary scaffold for engraftment," they point out.

Although implants provide an immediate breast mound and require less operative time, they are also associated with significant rates of contracture and extrusion, Khouri and colleagues note.

The other standard reconstruction procedure, tissue flap reconstruction, provides reliable natural tissue replacement but requires extensive surgery. It is also associated with significant early complication rates that often require hospitalization in the intensive care unit, the editorialists say.

They point out that in a survey of female plastic surgeons, most said they would not choose flap reconstruction for themselves or their loved ones. "The disconnect between women surgeons' preferences and clinical practices likely stems from the inability of the patient to conceive of the extent and invasiveness of the surgery," Khouri and colleagues write.

"Important Adjuct Procedure"

"Fat grafting should be considered an important adjunct procedure in breast reconstruction, which allows a woman to correct a defect resulting from lumpectomy or undergo finishing touches on a reconstructed breast," stated plastic surgeon and breast reconstruction specialist Constance Chen, MD, from Lenox Hill Hospital, New York City, in a press release issued after publication of the study and accompanying commentary.

Chen, who is also clinical assistant professor of plastic surgery at Weill Cornell Medical College, New York City, warns that achieving the ideal breast reconstruction may take time and patience. "While it is tempting to opt for short-term quick fixes, the reality is that breast reconstruction after mastectomy should be considered a process rather than a single procedure. Even with the most advanced techniques and superior surgical skill, small follow-up adjustments can help improve outcomes," she said.

Chen said that fat grafting can be useful for achieving improved symmetry or for filling in defects after breast conservation. However, repeat procedures may be required, and because the breast can be rebuilt only a bit at a time, fat grafting is not efficient for recreating an entire breast.

The grafted fat has no blood supply, so about 50% of the transferred fat will be reabsorbed by the body, she explained. "For that reason, it is necessary to overfill a defect to achieve a woman's goals. A patient may also need repeated bouts of fat grafting to compensate for any resorbed fat."

Dr Krastev and coauthors have disclosed no relevant financial relationships. Dr Khouri is the inventor of the Brava device and has ownership interest in Lipocosm. He also invented the Lipografter (MTF Biologics) and receives royalties from the Musculoskeletal Transplant Foundation. The other authors have disclosed no relevant financial relatioships.

JAMA Surg. Published online October 10, 2018. Study, Commentary

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