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Intermediary Lipofilling in Irradiated Patients undergoing Two-Stage Breast Reconstruction: A Systematic Review and Meta Analysis
Pooja S. Yesantharao, MS1, Leen El-Eter, BS1, Waverley He, BS1, Katie Nolan, BS1, Helen Xun, BS1, Justin M. Sacks, MD MBA2.
1Johns Hopkins School of Medicine, Baltimore, MD, USA, 2Washington University in St. Louis School of Medicine, St. Louis, MO, USA.

PURPOSE: Post-mastectomy radiation therapy (PMRT) can severely impact prosthetic breast reconstruction outcomes. As clinical indications for PMRT expand, such complications may only continue to become more common. Studies have demonstrated that fat grafting to the irradiated chest wall prior to definitive reconstruction can enhance outcomes of two-stage implant-based breast reconstruction, by improving irradiated skin trophicity. Autologous fat grafting, therefore, may present a critical solution for irradiated patients who desire prosthetic breast reconstruction, though its use must be balanced against considerations for oncologic safety. This is a systematic review and meta-analysis of the impact of protective autologous lipofilling on outcomes in PMRT patients undergoing two-stage implant-based breast reconstruction.
METHODS: A review of English literature using the PubMed/MEDLINE databases between 2010-2020 was performed to identify articles on intermediary autologous fat grafting after PMRT in patients undergoing prosthetic breast reconstruction. Complication rates were pooled across studies using random-effects modeling and the DerSimonian-Laird method. Post-hoc sensitivity analyses were completed using the Hartung-Knapp-Sidik-Jonkman method. The Haldane-Anscombe correction was used for outcomes with low counts. All study analyses adhered to PRISMA guidelines.
RESULTS: In total, 8 studies met inclusion criteria, encompassing 189 breasts and 126 patients. Pooled random-effects modeling demonstrated that irradiated breasts with treated with. intermediary lipotransfer had improved clinical outcomes in comparison to matched historical controls. There was a decreased relative risk of overall complications (relative risk, RR: 0.6, 95% confidence interval, CI: 0.5-0.8), capsular contracture (RR: 0.7, 95% CI: 0.5-0.9), ulceration (RR: 0.9, 95% CI: 0.8-1.0), implant exposure (RR: 0.8, 95% CI: 0.7-0.9), and reconstruction failure (RR: 0.9, 95% CI: 0.8-1.0), though not all reached statistical significance. Furthermore, three of the 9 studies demonstrated that irradiated breasts treated with intermediary lipotransfer had a similar risk of complications to non-irradiated breasts (RR: 1.14, 95% CI: 0.04-1.56). There were no locoregional cancer recurrences. The pooled mean number of lipofilling treatments used after PMRT was 1.7 (pooled standard deviation: 0.3).
CONCLUSIONS: Fat grafting has been increasingly recognized as a powerful tool to rejuvenate irradiated skin and allow for expander-to-implant reconstruction in patients undergoing PMRT. By comprehensively reviewing the impact of fat grafting on irradiated mastectomy flaps with regards to safety, functional, and aesthetic outcomes, this study provides support for the use of protective lipofilling in patients undergoing implant-based breast reconstruction after PMRT. Furthermore, through systematic review, we created a set of best-practices and an algorithm for protective lipofilling in PMRT patients undergoing prosthetic breast reconstruction.


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