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ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 1  |  Page : 196-202

Feasibility of immediate dermal fat graft after conservative breast surgery


Department of General Surgery, Surgical Oncology, Faculty of Medicine, Menoufia University, Menoufia, Egypt

Date of Submission07-Sep-2021
Date of Decision10-Oct-2021
Date of Acceptance18-Oct-2021
Date of Web Publication18-Apr-2022

Correspondence Address:
Mostafa A. S. Dawoud
17 Mohamed Galal Hamad Miamy, Alexandria
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_162_21

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  Abstract 


Objectives
To evaluate the feasibility of using a dermal fat graft immediately after conservative breast surgery and the factors that may increase the possibility of complication incidence after surgery.
Background
Breast cancer is considered as one of the most common cancers affecting women and remains one of the world's biggest killers. Once diagnosed as a breast cancer patient, a woman is exposed to psychological trauma. Breast reconstruction is an integral part of treatment of breast cancer after surgery. Reconstruction may be either immediate at the time of mastectomy or delayed until after adjuvant treatment. The advantages of immediate reconstruction have proved to be much higher than the possible disadvantages, including less psychological effect and reduced cost due to one-stage surgery, superior cosmetic results, and shortening the time to start radiotherapy.
Patients and methods
This study was conducted on 40 female patients admitted to Surgical Oncology Unit, Menoufia University Hospitals, in the period between January 2020 and February 2021. They were diagnosed as having early breast cancer and were eligible for conservative breast surgery. Patients who had contraindication to breast conservative surgery were excluded from this study.
Results
Of 40 patients, six (15%) patients had complications within 1 month after surgery; delayed wound healing was seen in two patients, hematoma in two patients, and surgical site infection in two patients. Multiple complications were observed in one diabetic patient who had surgical site infection within 1 month and fat necrosis within 6 months after surgery.
Conclusion
Immediate breast volume replacement using a free dermal fat graft after conservative breast surgery can be done for selected patients with breast cancer to avoid postoperative complications.

Keywords: breast cancer, conservative surgery, free dermal fat graft, immediate breast reconstruction


How to cite this article:
Elgammal AS, Dawoud MA, El-Feky AM. Feasibility of immediate dermal fat graft after conservative breast surgery. Menoufia Med J 2022;35:196-202

How to cite this URL:
Elgammal AS, Dawoud MA, El-Feky AM. Feasibility of immediate dermal fat graft after conservative breast surgery. Menoufia Med J [serial online] 2022 [cited 2024 Mar 28];35:196-202. Available from: http://www.mmj.eg.net/text.asp?2022/35/1/196/343106




  Introduction Top


In the 1980s, breast-conserving surgery (BCS) followed by whole breast radiotherapy rapidly became the first-line procedure for early-stage breast cancer as it ensured local control and produced acceptable cosmetic results [1],[2].

Oncoplastic breast surgery originated to improve the esthetic result of BCS. Many factors are known to influence cosmetic outcomes, such as the tumor size and location in the breast parenchyma. Poor cosmetic results are related to larger tumors, especially relative to breast size and to inner quadrant tumors [3].

Oncoplastic surgery combining partial mastectomy with immediate volume replacement has been conducted for repairing partial defects in various locations and has achieved excellent results [4].

Autologous immediate free dermal fat graft is an emerging oncoplastic technique to improve the cosmetic outcome of BCS.

The advantages of immediate reconstruction have proved to be much higher than the possible disadvantage, including less psychological effect, reduced cost owing to one-stage surgery, superior cosmetic results, and shortening the time to start radiotherapy [1].

Dermal fat has many properties that make it an ideal filler: it is autologous, frequently abundant, soft, and easily accessible.

We studied the data of patients undergoing partial mastectomy followed by immediate breast reconstruction using Free Dermal Fat Grafting (FDFG) to determine what the risk factors for complications are and identified preoperative clinical factors associated with postoperative outcomes. We hypothesized that factors associated with complications may occur at a frequency that varies according to factors associated with the patient, in addition to oncological findings such as the tumor location, size of partial mastectomy, as well as the existence of systemic diseases such as diabetes mellitus.

The aim of this study was to evaluate the feasibility of using dermal fat graft immediately after conservative breast surgery and the factors that may increase the possibility of complication incidence after surgery.


  Patients and methods Top


This study was approved by the ethical committee of Faculty of Medicine of Menoufia University, and all patients were well informed and gave their consent.

This study was conducted on 40 female patients admitted to Surgical Oncology Unit, Menoufia University Hospitals, in the period between January 2020 and February 2021. They were diagnosed as having early breast cancer and were eligible for conservative breast surgery. Patients who had contraindication to breast conservative surgery were excluded from this study. Advanced breast cancer T3, T4, or N2; pregnancy; multicentric tumor or bilateral cases; metastatic cases; and contraindication to radiotherapy such as skin disease, systemic lupus, and previous radiation were excluded from the study.

Metastatic workup was free in all patients, including chest computed tomography with contrast, pelviabdominal ultrasonography, and bone scan. All patients were candidates for breast-conserving surgery, regarding the size and location of the tumor, and also all selected cases gave no history of any abnormal skin diseases.

The patients were informed about the advantages and the disadvantages of BCS, regarding the possibility of local recurrence at the same breast, and on the use of high doses of adjuvant radiotherapy.

The operative technique was as follows: after marking the site of the mass and its location, an elliptical incision was marked in all patients [Figure 1]. The width of the ellipse depends on the location of the mass and how far the tumor is from the skin. A wide local excision of the tumor was done through this incision; the excision was extended deeply till the pectoral fascia, with a safety margin of about 2 cm all around the tumor. A separate lazy 'S' skin incision was done [Figure 2] for axillary dissection in all patients except in nine cases in whom the tumor was located at the upper outer quadrant near the axilla, in which breast and axillary incision is possible through the same site. After that, the defect after partial mastectomy was measured intraoperatively to decide the size of free dermal fat graft from the lower abdomen.
Figure 1: Elliptical incision at the site of tumor with dissection till pectoral fascia.

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Figure 2: Axillary clearance.

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After good hemostasis, another elliptical incision was done in the lower abdomen for dermal graft [Figure 3]. In situ de-epithelialization and sharp dissection was done. A free dermal fat graft was harvested as a columnar-shaped specimen. Horizontal and craniocaudal thicknesses were measured based on the measured postpartial mastectomy defect and more 20% in size. The free dermal fat graft was inserted in an ideal direction that fit the defect with the dermis facing the surface of the pectoralis major muscle. Suction drain was inserted in the axilla. Sutures was done to fix the dermal graft, and then direct closure of wounds was done [Figure 4]. Finally, dressing was done and an elastic bandage was applied. Patients were followed up 24 h postoperatively to avoid complications such as hematoma formation or discoloration of skin.
Figure 3: Elliptical incision in the lower abdomen to harvest dermal fat graft.

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Figure 4: Direct closure of wound.

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The patients received antibiotic, anti-edematous, and analgesic treatment and then were discharged on the second day postoperatively. Removal of drain was done after 10 days, and stitch removal was done. High-compression sports bra was used to attain immobilization of the graft. The patients were followed up in the planned outpatient clinic visits after two weeks, after 1 month, then 3 months later on for examination, and followed up finally every year later by mammograms.

Postoperative radiotherapy was started within 12 weeks; female patients received external beam radiation to the whole breast in a schedule of five sessions a week.

Statistical analysis

Data were fed to the computer using IBM Corp. Released 2016. IBM SPSS Statistics for Windows, Version 24.0. Armonk, NY: IBM.

Qualitative data were described using number and percent. Comparison between different groups regarding categorical variables was tested using χ2 test.

Quantitative data were described using mean and SD for normally distributed data.

For normally distributed data, comparisons between two independent population were done using independent t test.

Significance test results are quoted as two-tailed probabilities. Significance of the obtained results was judged at the 5% level.



Where X = the sum of all observations.

n = the number of observations.



Where

Σ (XiX)2 = the sum of squares of differences of observations from the mean.

Student (unpaired-sample) t test:

It is used for comparison between the means of different sample groups. The t is calculated as follows:



Where

X1 = Mean of first group.

X2 = Mean of second group.

S1 = SD of the first group.

S2 = SD of the second group.

n1 = Sample size of the first group.

n2 = Sample size of the second group.

χ2 test:

It tests the association between qualitative nominal variables; it is performed mainly on frequencies. It determines whether the observed frequencies differ significantly from expected frequencies.



Where E = expected frequency.

O = observed frequency.




  Results Top


The mean age of the studied patients was 49.5 years old. Two patients had a positive family history. The mean size of the resected partial mastectomy was 13.90 cm; the smallest was 4 cm and the largest one was 26 cm.

The demographic data and preoperative characteristics of the primary tumor are shown in [Table 1] and [Table 2].
Table 1: Demographic data among studied group

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Table 2: Distribution of the studied patients regarding site, size, and tumor stage

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Five female patients had diabetes mellitus and four had hypertension; three of them had both diseases. A total of 12 cases showed the presence of suspicious lymph nodes preoperatively either clinically or radiologically (30%).

Three (7.5%) cases received neoadjuvant chemotherapy and then received whole breast radiotherapy and post dose to post operative within 6 months. Moreover, 37 (85%) cases received postoperative whole breast radiotherapy and post operative after 12 weeks.

Postoperative complications were as follows: complications occurred in six patients within 1 month after surgery, where delayed wound healing was seen in two, which were managed conservatively with daily dressing and healing completed after 1 month; hematoma was seen in two, which were evacuated at the bedside and no surgical intervention was done; and surgical site infection was seen in two cases, which were managed conservatively with antibiotic therapy and daily dressing.

No recurrence of tumor was seen within 1 year after surgery. Complications were observed in one of 14 patients who had a tumor in upper inner quadrant; one of nine female patients who had a tumor in the upper outer quadrant; one of five female patients who had a tumor in the lower inner quadrant; and three of 11 patients who had a tumor in the lower outer quadrant. Complications in the lower quadrant were more than those in the upper, but P was not significant.

Of 21 female patients with T1, four had complications and two of 18 patients with T2 had delayed healing. Complications occurred in six female patients who had tumor stage as N0.

Of 35 nondiabetic patients, two had complications. However, four of five diabetic patients had delayed healing and wound infection. The P value was significant, which means that diabetic patients are more liable to complications.

Of 36 nonhypertensive patients, three had wound infection. However, three of four hypertensive patients had a hematoma and delayed healing.

The P value was significant. The possibility of complications increases with hypertension.

The relation between the incidence of complication and comorbidity disease is shown in [Table 3].
Table 3: Relation between the incidence of complications and comorbidity diseases

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The mean age of female patients who had complications was 60.8 years, whereas the mean age of female patients without complication was 47.6 years. The P was significant. Old age increases the possibility of complications. The mean size of resected partial mastectomy that showed complications was 22.0 cm and mean size that passed without complications was 12.5 cm. The P was significant. An increase in the size of resected partial mastectomy increases the possibility of complications. The relation between the incidence of complications and age and size is shown in [Table 4].
Table 4: Relation between the incidence of complications and age and size

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  Discussion Top


Oncoplastic breast surgery, which combines the concepts of oncologic and plastic surgery, is becoming more common worldwide [4].

Oncoplastic breast surgery initially originated to improve the esthetic results of BCS, the indications of which have grown significantly in recent years, ranging from small, wide excisions limited to 10–15% of the breast to partial mastectomies [5].

Usually, these procedures include quadrantectomy and lumpectomy. In quadrantectomy, a wide excision is usually performed, including skin and underlying muscle fascia. In lumpectomy, the objective is tumor excision without skin resection and with negative surgical margins [6].

In spite of the acceptance that most BCS defects can be managed with primary closure, the aesthetic outcome may be unpredictable and frequently achieve an unsatisfactory outcome [7]. In fact, ~10–30% of patients subjected to BCS are not satisfied with the aesthetic outcome. The main reasons are related to the tumor resection, which can produce asymmetry, retraction, and volume changes in the breast. In addition, radiation can also have a negative effect on the native breast. The main clinical aspects are related to skin pigmentation changes, telangiectasia, and skin fibrosis. In the glandular tissue, local radiation causes fibrosis and retraction [8].

Mild deformation can be corrected using minor procedures such as transposition of local flaps, wide undermining, and conization of the residual breast tissue [9]. Wide local excision without immediate volume replacement is associated with breast retraction leading to cosmetic failure in one-third of patients. These severe defects require immediate or delayed transposition of suitable tissue or implants [10].

Using latissimus dorsi muscle transposition, one of the most popular methods, sufficient breast tissue resection for tumor-free margins can be achieved with subsequent breast tissue deficiency immediately repaired using transposition. Elnahas et al. [11] reported that immediate volume replacement with latissimus dorsi muscle flap can avoid many of the cosmetic issues associated with extensive local resection. However, this technique is better suited to patients with laterally located tumors and requires complete sacrifice of a large muscle that represents an adequate donor for reconstructive surgery after total mastectomy if the patient requires further treatment owing to positive margins after initial Breast Conservation Therapy (BCT).

The aim of this study was to evaluate the feasibility of using immediate dermal fat graft in partial breast reconstruction after conservative surgery for breast cancer.

This study was conducted on 40 female patients admitted to the Surgical Oncology Unit of Menoufia University Hospitals in the period between January 2020 and February 2021. They were diagnosed as having early breast cancer and eligible for conservative breast surgery and immediate reconstruction with a dermal fat graft.

The mean age of the patients was 49.5 ± 11.36 years, and the patients with positive family history represented 5% of the patients. Delayed wound healing was observed in two patients who were 60 years old.

In our study, the most common site was upper limb (35.0%), whereas the least frequent site was C (2.5%). Inner quadrant tumor was found in 16 patients. Many factors influence the cosmetic outcome, such as tumor size and location in the breast parenchyma. Poor cosmetic results are associated with larger tumors, especially relative to breast size and with inner quadrant tumors.

In our study, the cosmetic results for tumors in the inner quadrant in 16 patients were satisfactory, which agrees with Kijima et al. [12], who performed wide excision for cancer lesions of the upper inner quadrant and immediate reconstruction using an FDFG from the lower abdomen with axillary lymphadenectomy.

In our study, most cases were in tumor stage T2 (45.0%). Lymph node status was 70.0% N0 and 30.0% N1. No recurrence was reported in the postoperative follow-up period. In the study by Stumpf et al. [13] on oncologic safety of immediate autologous fat grafting for reconstruction in BCS, the majority of the patients in this study were in stage II (45.9%) and the number of lymph nodes was the sole independent risk factor for local recurrence (P = 0.045). No significant differences in disease-free survival rates were found between the groups. At a mean follow-up of 5 years, no significant differences in locoregional recurrence rates were found between patients who received immediate Autologous fat grafting (AFG) and those who underwent BCS alone. These findings corroborate previous research demonstrating the oncological safety of immediate AFG reconstruction, further suggesting that this technique as a safe, effective way to achieve optimal cosmetic outcomes in primary breast cancer surgery without jeopardizing oncologic outcomes [13].

The size of resected partial mastectomy ranged from 4.0 to 26, with mean of 13.90 ± 11.36. The size of the resected specimen influences the cosmetic result postoperatively owing to need of larger volume replacement. Hematoma formation and wound infection happened in two out of six patients with resected specimen of 20 cm.

In the study by van Turnhout et al. [14], localized infections occurred in four patients, and all were treated effectively with oral antibiotics. Fat necrosis that required excision under local anesthesia occurred once. The overall cosmetic appearance was rated 5.1/10 before and 7.2/10 after reconstruction (P < 0.01). A significant improvement was noted in breast symmetry, volume, shape, and scarring [14].

The results of our study showed that the complications occurred in six (15.0%) patients between 1 and 12 months after surgery, with delayed wound healing in two, hematoma in two, and surgical site infection in two. Multiple complications were observed in one patient who had Surgical site infection (SSI) within 1 month and fat necrosis within 6 months after surgery. No recurrence of tumor was seen among patients 1 year after surgery. These data agree with the study conducted by Biazus et al. [15], titled 'the breast-conserving surgery with immediate autologous fat grafting reconstruction: oncologic outcomes.' They found that seven (10.8%) patients developed surgical complications. One patient had a mild wound infection, which easily resolved with antibiotics. Six patients had either a fat necrosis or an oil cyst, which was detected by routine follow-up examination [15].

García et al. [16] published their preliminary results of 37 immediate reconstructions using AFG after BCS. They included both benign and malignant tumors, avoiding AFG in the same region of the quadrantectomy. All cases showed excellent aesthetic results within 1 year of follow-up, even after receiving radiotherapy. The rate of complications was low and oncologic safety was not compromised [16].

Based on these laboratory observations, there is a reasonable concern whether lipofilling is really a safe procedure to be used in breast cancer treatment.

Autologous fat grafting is an increasingly popular procedure performed as an adjunct to implant-based breast reconstruction after mastectomy to correct step-off and contour deformities. It is traditionally performed as a revisionary procedure following permanent implant placement or at the second stage reconstruction, and the surgical safety and aesthetic benefits of this procedure have been previously demonstrated.

The results of our study showed that the most common risk factors causing complication were diabetes mellitus and hypertension as comorbidities, increased age, and increased size of resected partial mastectomy.

In our study regarding patient satisfaction, the majority of the patients (60.0%) were very satisfied, 25.0% were satisfied, and only 15% were unsatisfied, which was owing to delayed healing and need of postoperative radiotherapy.

In agreement with our study was the study by Biasio et al. [17] on oncoplastic BCS using immediate dermal fat graft. They found that the patient satisfaction rates were 84.0% and concluded that FDFG oncoplastic surgery in a population of patients with breast cancer selected for low oncological risk seems to be oncologically safe, with a good cosmetic outcome and a high level of satisfaction of the women treated [17].

The main limitation of the present study is the short oncological follow-up; however, the use of this kind of procedure is limited and only minor studies with short follow-up periods have been published.


  Conclusion Top


The use of immediate free dermal fat graft after conservative breast surgery for breast cancer is a simple method for volume replacement and gives satisfactory cosmetic results, especially in tumors of the inner and central regions of the breast, with minimal complications related to age of patient and comorbidities.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Elnahas W, Khater A, Hamdy M, Hamed E, Eldamshety O, Hegazy M. Latissimus dorsi mini-flap as a volume replacement technique after partial mastectomy for breast cancer in the upper and central breast quadrants: a single center experience. Surg Sci 2016; 7:496.  Back to cited text no. 11
    
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Kijima Y, Koriyama C, Fujii T, Hirokaga K, Ishigure K, Kaneko T, et al. Immediate breast volume replacement using a free dermal fat graft after breast cancer surgery: multi-institutional joint research of short-term outcomes in 262 Japanese patients. Gland Surg 2015; 4:179–194.  Back to cited text no. 12
    
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Stumpf CC, Zucatto ÂE, Cavalheiro JA, de Melo MP, Cericato R, Damin AP, et al. Oncologic safety of immediate autologous fat grafting for reconstruction in breast-conserving surgery. Breast Cancer Res Treat 2020; 180:301–309.  Back to cited text no. 13
    
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van Turnhout AA, Fuchs S, Lisabeth-Broné K, Vriens-Nieuwenhuis EJ, van der Sluis WB. Surgical outcome and cosmetic results of autologous fat grafting after breast conserving surgery and radiotherapy for breast cancer: a retrospective cohort study of 222 fat grafting sessions in 109 patients. Aesthetic Plast Surg 2017; 41:1334–1341.  Back to cited text no. 14
    
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García RM, Alonso VG, Doménech ME. Fat grafting in immediate breast reconstruction. Avoiding breast sequelae. Breast Cancer 2016; 23:134–140.  Back to cited text no. 16
    
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Biasio FD, Bertozzi S, Londero AP, Almesberger D, Zanin C, Marchesi A, et al. Surgical and oncological outcomes of free dermal fat graft for breast reconstruction after breast-conserving surgery. Adv Clin Exp Med 2018; 27:773–780.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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