Revisiting options for improving results of breast reconstruction

There are a range of options for reconstruction following breast cancer surgery. When a mastectomy is performed, reconstruction can be achieved using various forms of implants, or with natural tissue taken from other parts of the body to re-form the breast. Whether or not a woman chooses to pursue breast reconstruction is a very personal choice. Many women experience an excellent quality of life without reconstruction. However, for some women, undergoing reconstruction after a mastectomy can help improve certain aspects of self-image and well-being.

A new option when reconstruction results are disappointing

Unfortunately, despite advances in plastic and reconstructive surgery, the final cosmetic result of breast reconstruction can occasionally be less than satisfying. Women may have contour irregularities (e.g. indentations, bumps, or ripples), asymmetry, or defects in the reconstructed breast resulting in a disappointing cosmetic appearance. For these women, a new option is available to help correct the deformity. This procedure is fat grafting, also called autologous fat transfer or lipo-filling. It involves removing fat tissue from other parts of the body using liposuction techniques, processing the tissue into a liquid, and then injecting it into the site of the reconstruction to help improve contour and appearance. The tissue is usually taken from the thighs, belly, or buttocks.

Actually, fat grafting is not a new procedure. The process has been available for quite some time. However, it was not used often due to concerns about its safety. The good news is that a growing body of data suggests that the procedure is safer than originally thought, especially because of new and improved techniques that have reduced complication rates.

Recent data from the largest clinical trial investigating patient-reported outcomes following fat grafting showed that fat grafting may improve outcomes rated by patients undergoing breast reconstruction. The findings were reported last year in JAMA Surgery. The study was conducted between February 2012 and July 2016 at 11 sites associated with the Mastectomy Reconstruction Outcomes Consortium Study. Eligible patients included women over the age of 18 who had had breast reconstruction after mastectomy and were available to be followed in the study for at least two years. All types of breast reconstruction procedures (implant and natural tissue) were included in the study.

A total of 2,048 women were evaluated across centers in the United States and Canada. The average age of study participants was 49.4 years. The study found that women who required fat grafting to correct deficiencies in their breast reconstruction were able to achieve equal rates of breast satisfaction, psychosocial well-being, and sexual well-being, compared with women who did not require fat grafting, despite the fact that their initial ratings in these areas were lower prior to correcting the deformities.

An interesting question not explored in the study is whether we should use fat grafting to improve cosmetic results after breast conserving cancer surgery (i.e. lumpectomy). This is still an area of controversy due to concerns about fat cells stimulating potential residual cancer cells, and therefore increasing the risk of cancer recurrence. Although the data are not conclusive — and in fact, emerging studies suggest that fat grafting may not impact local recurrence — the potential risk still limits enthusiasm for fat grafting following breast conserving surgery.

What else is important about this study?

This study is the first of its kind to provide patient-reported outcomes about fat grafting, and reflects a growing trend of incorporating patient-reported outcomes into clinical trials. Gaining a better understanding of outcomes from the patients' perspective helps researchers and clinicians to design and deliver care that truly meets the personal preferences and treatment priorities of women diagnosed with breast cancer.

I'd like to thank my colleague Dr. Dhruv Singhal, a plastic surgeon at Beth Israel Deaconess Medical Center, for his contributions to this post.