Sir:
I read with interest the article by Knackstedt et al.1 concerning fat necrosis following autogenous fat grafting and postoperative changes that can lead to unnecessary diagnostic studies. The authors made a great contribution to the literature regarding the early unplanned procedure and its consequences as they relate to patient and multidisciplinary team concerns. In my view, the main radiological findings following autogenous fat grafting are related to fat necrosis, which results in microcalcifications, oil cysts, and palpable lumps.2 It is important to emphasize that all procedures related to breast surgery, whether it is breast conservation, reduction/augmentation mammaplasty, or flap transfer, are at risk of fat necrosis.3 Thus, understanding the risk factors for fat necrosis and other complications following autogenous fat grafting would help to improve the informed consent process and assist plastic surgeons, as well as radiologists and breast surgeons, with treatment decisions. In addition, medical societies and government agencies are worried about unnecessary examinations that may expose patients to invasive procedures, which elevate healthcare costs and lead to harm, including fear, anxiety, and discomfort. Unnecessary medical tests can also lead to false-positive results, which frequently lead to other tests, a phenomenon known as diagnostic cascade.
The present study found that postoperative biopsies were performed 17 times in 13 patients, with four patients undergoing two biopsies. The most common diagnosis was fat necrosis, followed by benign lesion. No cases of local relapse were observed on biopsy, and no significant association was noted between autogenous fat grafting and local recurrence in patients previously treated for breast cancer and submitted to reconstruction. This last rate is lower than rates reported in the other case-control series, in which the local recurrence rate was 1.9 percent per year following autogenous fat grafting.4 This discrepancy may be related to the absence of breast-conserving surgery cases in their series.
Despite the great contribution of the authors to this subject, there are limitations in evaluating retrospective studies, since they include heterogeneous, nonmatched, different breast cancer profiles and surgical treatments. Confounding variables, such as cancer-related aspects (histology/receptor status) and resection margins, could also directly influence the local recurrence rate and outcome. In fact, it is not clear whether the timing of autogenous fat grafting has an impact on the incidence of local relapse, considering that breast cancers of various histological stages and receptor status present specific local recurrence behaviors, often culminating between the first and fifth year of follow-up.5 Unfortunately, in the present study, there was no mention of these aspects.
In addition, the authors mentioned a mean follow-up of 2.4 years after the first autogenous fat grafting procedure (range, 1.3 to 6.9 years), and concluded that autogenous fat grafting has a negligible impact on local recurrence. A large part of the clinical series described a follow-up of around 3 years after autogenous fat grafting. In theory, local effects from adipose-derived stem cells would start to take effect during the first months and up to a year after autogenous fat grafting. However, it is uncertain whether local relapse that occurs more than 3 to 4 years after cancer treatment and reconstruction can be attributed directly to autogenous fat grafting or to the natural behavior of cancer.5 Thus, additional studies are necessary and should evaluate the behavior of autogenous fat grafting over a follow-up of at least 5 years after the initial procedure. However, this kind of retrospective study would be complex to design and conduct prospectively. In fact, at present, clinical randomization would be almost impossible because of the need for a comparable alternative to autogenous fat grafting, and patients tend to recognize the advantage of the technique once it enhances their reconstructive procedure. Despite these limitations, the present study shows no evidence of increased local recurrence rate associated with autogenous fat grafting in patients previously treated for breast cancer. This evidence should be evaluated with other, equivalent case-control studies to establish safe indications for autogenous fat grafting in this scenario.
In conclusion, the authors have performed an important study that is relevant to the informed treatment decision-making process. In addition, the authors should be congratulated on proposing a clinical pathway and surveillance strategies for patients who undergo implant-based breast reconstruction with autogenous fat grafting and present a suspicious palpable mass during the follow-up.
DISCLOSURE
This work was not supported by any external funding. Dr. Alexandre Mendonça Munhoz is a member of the advisory board of Establishment Labs.
REFERENCES
1. Knackstedt RW, Gatherwright J, Ataya D, Duraes EFR, Schwarz GS. Fat grafting and the palpable breast mass in implant-based breast reconstruction: Incidence and implications. Plast Reconstr Surg. 2019;144:265–275.
2. Chan CW, McCulley SJ, Macmillan RD. Autologous fat transfer: A review of the literature with a focus on breast cancer surgery. J Plast Reconstr Aesthet Surg. 2008;61:1438–1448.
3. Sampaio Goes JC, Munhoz AM, Gemperli R. The subfascial approach to primary and secondary breast augmentation with autologous fat grafting and form-stable implants. Clin Plast Surg. 2015;42:551–564.
4. Petit JY, Botteri E, Lohsiriwat V, et al. Locoregional recurrence risk after lipofilling in breast cancer patients. Ann Oncol. 2012;23:582–588.
5. Krastev TK, Schop SJ, Hommes J, Piatkowski AA, Heuts EM, van der Hulst RRWJ. Meta-analysis of the oncological safety of autologous fat transfer after breast cancer. Br J Surg. 2018;105:1082–1097.
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