Optimizing Second-Stage Pre-Pectoral Implant Placement and Concomitant Fat Grafting after Tissue Expansion
Alisa O. Girard, MBS, Christopher D. Lopez, MD, Christina M. Ambrosino, BS, Katherine J. Zhu, BS, Kristen Broderick, MD
Johns Hopkins University School of Medicine, Baltimore, Maryland, US
Background: Pre-pectoral implant-based breast reconstruction is often supplemented by autologous fat grafting to optimize aesthetic outcomes. Large-volume lipofilling may create elevated local pressures and result in poor graft-to-recipient interface and necrosis. Therefore, when reconstructive surgeons utilize both implants and fat transfer for breast reconstruction, surgery usually entails several rounds of modest fat transfer to minimize risks. However, the limits of fat grafting at time of implant placement are not known.
Methods: A single institution retrospective review from July 2016 to February 2022 was performed of all patients who underwent (1) mastectomy, (2) pre-pectoral tissue expander placement, (3) pre-pectoral permanent silicone or saline implant placement, and (4) at least one round of autologous fat transfer. Breasts were excluded if they underwent flap reconstruction, sub-pectoral reconstruction, or implant removal without replacement prior to fat transfer. Breasts with a follow-up time less than 30 days after most recent fat transfer were excluded. Student t-test and chi square test were used (alpha 0.05).
Results: A total of 95 patients with 157 breasts met inclusion criteria. Of these, 82 breasts underwent a single round of fat grafting at the time of implant placement (Group 1). The remaining 75 breasts underwent fat grafting that occurred in multiple rounds or in delay to implant placement (Group 2). Groups were comparable with regards to patient demographics, cancer vs. prophylactic mastectomy, and radiation therapy. Group 1 received more fat at the time of implant placement (100cc, IQR 55-140cc, p<0.0001). However, total fat volume in Group 2 did not significantly exceed that of Group 1 until after two additional rounds of fat transfer (128.5cc, IQR 90-130cc, p<0.01). Within Group 2, 17 breasts underwent 3 to 5 rounds of fat grafting. Groups underwent comparable tissue expander fill (385.9cc vs. 421.4cc, p=0.1), although Group 1 received smaller implants (441.5cc vs. 508.7cc, p<0.005). Group 1 underwent fewer planned implant- and fat graft-inclusive operative procedures compared with Group 2 (1.0 vs. 2.2, p<0.0001). There was no significant difference in the rate of fat necrosis between groups after the first round (15.9% vs. 9.3%, p=0.2) and final round (15.9% vs. 12.0%, p=0.5) of fat grafting. Complication rates were similar between groups (3.7% vs. 8.0%, p=0.2).
Conclusions: A two-stage approach of pre-pectoral implant placement with a single round of larger volume fat transfer reduces overall number of operative procedures without increased risk of fat necrosis or other post-operative complications.
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