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Autologous fat grafting (AFG) is a popular method for soft tissue augmentation and reconstruction due to its regenerative potential and minimally invasive nature.
However, variability in fat graft retention remains a major limitation. While research has focused on optimizing fat harvesting and processing techniques, the role of recipient site preparation has been understudied.
This trial evaluates whether preconditioning the recipient site – via pre-expansion, pre-heating, or both – could enhance fat graft retention around the breast six months postoperatively.

In a prospective, multicenter RCT with a 2×2 factorial design, 60 female patients
were assigned to one of four groups: (1) pre-expansion using the Kiwi® VAC-6000M with PalmPump™, (2) pre-heating using the HILOTHERM® Calido system, (3) a
combination of both interventions, or (4) a control group without preconditioning. The primary outcome was the percentage of fat graft volume retained at the breast at
six months relative to baseline at screening. Secondary outcomes included scar quality (Patient and Observer Scar Assessment Scale), pain levels (Numeric Rating Scale), and complications (Clavien-Dindo classification).

No statistically significant difference in fat retention was observed between the treatment and control groups at
six months. All groups (including control) showed improvement in scar quality and reduced pain, though the improvement was not different between arms. All preconditioning methods were well tolerated, and no serious adverse events were reported.

This is the first RCT to evaluate recipient site
preconditioning in AFG around the breast. The interventions did not yield statistically significant improvements in fat graft survival, pain or scarring. Given their safety, feasibility, and the biological rationale supporting their use, these techniques warrant further
investigation in larger, adequately powered trials. Future studies should focus on identifying patient subgroups most likely to benefit and exploring long-term outcomes
beyond six months.

Autologous fat transfer is a widely used surgical technique, chosen by numerous plastic surgeons for breast augmentation surgery. This technique is based on three steps: 1. harvesting of the lipoaspirate from the patient, 2. centrifugation and removal of the top, oily, layer, and 3. implantation in the patient’s breast(s). It has been associated with various complications, including post-surgical fat resorption, as measured quantitatively with MRI, CT, and other 3D-quantification systems. The purpose of this paper is to explore the ways in which cell-assisted lipotransfer is different from autologous fat transfer and how and why adipose-derived stem cells may contribute towards limiting fat resorption.

Adipose-derived stem cells have been explored as a means of addressing fat resorption. They can be separated from the lipoaspirate following centrifugation, and enzymatically purified from unwanted debris, with collagenase, forming the stromal vascular fraction. The stromal vascular fraction is then recombined with the graft volume prior to implantation. This novel technique, referred to as “cell-assisted lipotransfer”, has shown promising results in terms of reducing fat resorption. These results are due to the pro-angiogenic and pro-adipogenic ability of the stem cells, which allow the graft to address the conditions of ischemia more effectively than autologous fat transfer. In this paper, we review available systematic reviews and meta-analyses regarding graft survival and complication rates, comparing cell-assisted lipotransfer against autologous fat transfer.

Numerous studies investigating VEGF, FGF, and PRP, all associated with improvement of ADSC survival, highlight the potential of their external administration, to stimulate ADSC survival and the promotion of a pro-angiogenic lineage, across human and murine models.

To conclude, we discuss and evaluate CAL as an alternative to AFT in breast augmentation surgery. ADSCs have been shown to reduce the fat resorption rates associated with AFT, with varying levels of success, and potentially increased complication rates. The comparison of different isolation systems has shown differing outcomes, which is a limitation of CAL in terms of large-scale use in clinical practice. Furthermore, the legal framework of tissue culture legislation constitutes an additional barrier in the United States.

Hybrid breast reconstruction after mastectomy combines expander-to-implant reconstruction with serial autologous fat grafting (lipofilling) to increase soft tissue thickness respectively improve implant coverage, and eventually aesthetic outcome. However, lipofilling may be associated with recipient-site complications, including microcalcifications, oil cysts, and fat necrosis, which are relevant for postoperative surveillance and patient counseling. This study aimed to assess the incidence of clinically relevant radiological findings after multiple lipofilling sessions.

A retrospective single-center study included patients who underwent bilateral, multi-stage hybrid breast reconstruction and postoperative breast MRI 3 months after the final lipofilling session. MRI scans were independently reviewed by two radiologists for fat necrosis and oil cysts, with lesions >1 cm analyzed separately. Moreover, radiological findings from routine long-term radiological follow-up were assessed, including suspicious lesions requiring further imaging and/or biopsy.

Twenty-five patients were evaluated; 2 were excluded due to inadequate or incomplete imaging, resulting in 46 breasts for final analysis. Mean age at mastectomy was 48±8 years, with a mean of 2.6 (range 1–4) lipofilling procedures per breast (120 lipofilling procedures in 60 surgical procedures). Postoperative MRI detected 1 case of fat necrosis (2.2%), 8 oil cysts smaller than 1 cm (17.4%), and 1 oil cyst larger than 1 cm (2.2%). During routine ultrasound follow-up, suspicious lesions were identified in 7 breasts (15%) at a mean interval of 18±9 months after the last lipofilling session. In 4 cases, ultrasound or MRI confirmed fat necrosis; in 3 cases, biopsy was required to confirm suspicious fat necrosis, resulting in a 3% biopsy rate per patient for non-oncological lesions.

Postoperative imaging after repeated lipofilling in multi-stage hybrid breast reconstruction demonstrates a low rate of clinically relevant complications. During long-term follow-up of these “oncological” patients, ambiguous or suspicious radiological findings may require further radiological evaluation, eventually resulting in biopsy to rule out breast cancer or disease recurrence. Nevertheless, these findings support the safety of serial lipofilling, while highlighting the importance of appropriate surveillance and patient counseling.