#PRSJournalClub Wrap-Up: Lipofilling of the Breast Does Not Increase the Risk of Recurrence of Breast Cancer: A Matched Controlled Study (Feb 2016)

by Aaron Weinstein, Managing Editor

The February Edition of the PRS Journal Club- lead by Resident Ambassadors Sammy Sinno (@sammysinnoMD), Amanda Silva (@AmandaKSilvaMD), and Raj Sawh-Martinez (@docrfsm)-  was a very informative session.

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  • The Resident Ambassador’s picks and paired classics for the February issue are offered FREE- oh so, free- on PRSJournal.com. We hope you had many discussions and debates about these amazing articles.
  • The podcasts from are available on our website, via iTunes, and on Youtube and have been listened to hundreds of times.
  • And our second live Twitter #PRSJournalClub discussion, featuring Q&A with two of the authors was very informative, exciting, and interactive.
    • Some active people even performed an ancient academic analog ritual during our digital discussion. Check it out:feb jc 1

As always, if you missed the live chat, or want to re-read and have easy access to some of the best interactions between the authors, residents, patients, surgeons and other interested parties, we’ve put together the following re-cap.

The article: Lipofilling of the Breast Does Not Increase the Risk of Recurrence of Breast Cancer: A Matched Controlled Study

The authors:
Steven Kronowitz- @StevenKronowitz
Summer Hanson- @DrSummerHanson
Patrick Garvey
Cosman Camilo Mandujano
Jun Liu
Benjamin Smith
Reshma Jagsi
Limin Hsu
Vicente Valero

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The article had already been picked up in social media and mainstream media as a very important and interesting topic.

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So, it was no surprise that the Q&A was active and engaging.

Our amazing authors got caffeinated and jumped right in to the PRS Journal Club!

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The Best Tweeted Q&A:

  1. Question: Do you wait a certain time period after mastectomy to fat graft?

    • From: Amanda Silva
    • Answer: Summer Hanson – It varies with other treatments, procedures, etc. Usually 6-12 months after mastectomy, longer if PMRT.
    • Answer: Steven Kronowitz- Depends on the ability to have a tissue plane to inject the fat graft.
    • Question: Amanda Silva- When do you tend to do immediate fat grafting?
    • Answer: Steven Kronowitz- In some patients, fat grafting can be performed immediately into the pectoralis muscle.
  2.  Question: Should we avoid fat grafting in patients undergoing hormone therapy?

    • From: Sammy Sinno
      • Recap: Amanda Silva- We do NOT need to avoid fat grafting in pts undergoing hormone therapyAnswer: Steven Kronowitz- I don’t think we need to avoid.
    • Question: Amanda Silva- What do you make of finding possible risk in hormone therapy patients? Study limitation or really required further study?
      • Answer: Steven Kronowitz- My inclination is study limitation however I assume many more studies will be coming forward which should shed light.
    • Answer: Summer Hanson-  I don’t think it precludes use in hormonal therapy. @ASPSMembers initiatives like GRAFT will help. My favorite part of research- hypothesis-driven studies answer one question and raise a few more. Still, brings up more questions on the physiology and mechanisms of fat graft to bring back to the lab.
  3. Question: What are your thoughts on detecting recurrence in fat grafting for breast reconstruction?

    • From: Amanda Silva
    • Answer: Steven Kronowitz- The recurrence rate was only 1/4%. Acceptable range is between 1-1.5%
    • Answer: Summer Hanson- With Cancer History, radiographic or palpable abnormality can be stressful, warrants thorough evaluation.
  4. Question: Any donor site preference?

    • Answer: Steven Kronowitz- Other than inner thighs for face, no preference.
    • Discussion point: Daniel Del Vecchio- Donor site preference? Like it matters? Wherever you can.
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  5. Question. For patients needing radiation therapy, do you ever fat graft before XRT?

    • From: Raj Sawh-Martinez
    • Answer: Steven Kronowitz- Standard immediate two-stage implant fat graft at exchange for standard delayed reconstruction after radiation. If implant desired, you can fat graft the radiated chest wall and then subsequently place an expander. Then three monthls later will exchange for permanent implants. Not before, but soon after. If placed TE priort to XRT with plan for implant after XRT. Will perform interval fat grafting over the expander six weeks after the radiation. This allows three months for new blood vessel formation and maturation of new adipocytes.
      • F/up Question from Amanda Silva- Do you notice this decreases your implant/XRT related complications?
      • Answer: Steven Kronowitz- Yes. Objective is to decrease complications on exchange by changing the radiated environment to conducive to healing
    • Answer (cont’d): Steven Kronowitz- DTI Reconstruction use pre-pectoral plane with ADM then fat graft as revision to upper pole due to lack of pectoralis.
      • F/up Question. From Amanda Silva. Do you find you need additional fat grafting after XRT or does grafted fat tend to stay post-XRT?
      • Answer: Steven Kronowitz- Volume retention difficult with radiation multiple times. Preferred initial graftings enhance healing environment.
  6. Question: How do you process fat? Centrifuge? Revolve? Any difference in your opinion?

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    • Answer: Steven Kronowitz- I use Revolve even for cosmetic cases, breast and breast augmentation. Multiple process things are required with whole body liposarcoma and butt augmentation. Limitation is volume of 350 ML.Less fat necrosis and cysts with non-centrifugation approaches to filtration.
    • F/up Question: Pallab Chatterjee– Why stress for “cleaner” fat? Do we not want stromal portion?
      • Answer: Steven Kronowitz- we want mesenchymal bone marrow derived stem cells and vascular stroma limits contact with vascular used tissue bed. The other serous components take up volume and can limit graft take.
      • Answer: Summer Hanson- Less necrosis and cyst if less free lipid, cellular debris, mechanical disruption.
    • AnswerSummer Hanson- I use Revolve. Faster Processing. Cleaner fat versus centrifugation. Prospective Studies coming.
  7. Question. Cases more likely to be stage 0/1. Any difference offering fat graft in advanced disease?

    • From: Jordan Frey.
    • Answer: Steven Kronowitz- the study did not show a difference with stage of disease.
    • Recap: Jordan Frey- Thank you! No difference in breast cancer risk regardless of stage with fat graft!
  8.  Question. Do you lipofill alone or use as an adjunct in breast reconstruction?

    • From: Sammy Sinno
    • Answer: Steven Kronowitz- Adjunct for Breast Reconstruction
    • Answer: Summer Hanson- I think it’s a great adjunct for Breast Reconstruction
  9. Question. Do you wait for final pathology to be clear before fat grafting lumpectomy defects?

    • febjc9
    • Answer: Amanda Silva- at @UChicagoPRS we tend to do oncoplasty for larger lumpectomies & wait for final path #PRSJournalClub you?
    • Answer: Steven Kronowitz- Reasonable approach. I prefer immediate with unifocal tumors without microcalcs with intraop path.
    • F/up Question: Michelle Lee- Those are the lumpectomies you would fat graft immediately?
    • Answer: Steven Kronowitz- No, fat grafting immediately rare, can only inject surrounding areas, not defect, XRT may also decrease take. Those are the patients I perform oncoplasty immediately using remaining breast tissue, not fat graft.
  10. Question. How do you process fat? Does processing alter oncologic risk?

    • From: Sammy Sinno
    • Answer: Summer Hanson- Great Question! Randomized comparison going on here so time (should) tell. CRAFT/GRAFT may capture.
    • Answer: Steven Kronowitz- Non-centrist ion devices. Very good question about impact on oncology. Great variable for prospective study, technique of centrifugation. Companies making smaller devices for in small volume office fat graft, face etc. Probably obviate centrifugation, near future and other techniques ie Tefla rolling.
    • F/up Question from  Jordany Frey: Do you find differences in fat grafting after implant vs flap? Amound, areas grafted etc?
      • Answer: Steven Kronowitz- Latissimus Dorsi can fat graft immediately as wella sp ectoral muscle, even with prepectoral immediate implant. Implants full breast envelope grafting limits volume per session, increase by grafting pectoralis as well. Fat grafting diep flaps secondarily becoming more popular as opposed to adding implant or bipedicled flap.
      • Answer: Summer Hanson- I agree. Fat Graft DIEP later to add volume, smooth contour, soften PMRT skin flaps. Fat Graft LD/implant or implant alone to address contour, upper pole, and PMRT flaps. Fat Graft Volume can be limited by skin quality, subQ plane, vascularized tissue w/ implants alone.
    • F/up Question from  Sammy Sinno: Would be interested to see if techniques that preserve more ADSCs showed change.
      • Answer: Steven Kronowitz- Agreed. Data wasn’t available for this study prospective essential probably still ok.
  11. Question. Will fat grafting replace flaps for breast reconstruction?

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    • Answer: Summer Hanson- Not in my practice. Free Flaps are still an essential tool. #microsurgery. I fat graft as an adjunct to Breast Reconstruction.
    • F/up Question from Raj Sawh-Martinez- Maybe for small recon? For high Risk Anesth pt? Do U ever fat grafting alone?
      • Answer: Summer Hanson- I don’t fat graft alone for Breast Reconstruction w/ mastectomy. Partial defects can be effective.
  12. Question. Do you employ large volume lipofilling? Or prefer multiple smaller grafting sessions?

    • From Raj Sawh-Martinez
    • Answer: Summer Hanson- My practice is largely Breast Reconstruction rather than cosmetic, so it’s limited by native tissue. Average 50-250 mL in my series depending on skin flap/muscle thickness, PMRT, etc. If PMRT, I’m conservative and prepare patients for possible resorption, multiple sessions if needed.
  13. Question. Do you use oncoplasty ever instead of fat grafting for lumpectomy defects?

    • From Amanda Silva
    • Answer: Steven Kronowitz- Oncoplastic fat grafting in delayed setting after XRT. Oncoplasty is preferred in immediate and delayed before XRT which is preferred partial repair approach.
    • Answer: Summer Hanson- I prefer oncoplasty before XRT, ideally immediate. Fat Graft after if needed.
  14. Question. Do you see a difference between ADMs currently on the market?

    • From Chris Natale
    • Answer: Steven Kronowitz- I have always used human ADM, which I prefer, limited experience with non-human ADM.
  15. Question. What’s your preferred protocol for handling fat?

    • From Raj Sawh-Martinez
    • Answer: Steven Kronowitz- Revolve for all regions, even low volume face, then vary syringe volume and needle gauge based onlocation. Many mature adipocytes don’t survive transfer without cytoplasmic alterations, new preadipocytes/neovascularization. Potential disadvantage  is vacuum versus passive fat removal however stem cells and vasular stroma most important. Closed system good for sterility. Also if SQ/supraperiosteal/intramuscular injection of fat.
  16. Question: What do you think are some areas of future research in fat grafting for breast reconstruction?

    • From Amanda Silva
    • Answer: Summer Hanson- Great question! Where to begin? Prospective, randomized outcomes-based comparing processing methods. 3D imaging to quantify resorption related to harvest/processing/injection techniques. Basic science questions include ASC-supplementation of grafts; are SVF cells different from ASCs? What defines minimal manipulation and homologous use? What is safe in the same surgical procedure? Can we design grafts as targeted cellular therapeutics?

 

We hope this summary of the best Q&A exchanges has helped you better understand Lipofilling and its role in breast reconstruction.

We will see you in a few weeks for the LIVE PRS Journal Club Twitter discussion of “Prospective Analysis of Payment per Hour in Head and Neck Reconstruction: Fiscally Feasible or Futile?” on March 20 -21, with authors Benjamin Smith and Neil Tanna.

For now, we’ll leave you with Dr. Summer Hanson’s words of wisdom on the beauty of plastic surgery research:

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Thank you for joining the PRS Journal Club!

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