Breast Lipofilling: Is the Bra Really Full? Clinical Bra Pressure Measurement and In Vitro Testing of Processed and Unprocessed Fat Cells.

BACKGROUND: Breast lipofilling, a popular cosmetic and reconstructive procedure, involves the transplantation of autologous fat to enhance breast volume and contour. Despite its widespread use, cell processing and the aftertreatment remain controversial. This study investigates the pressure applied by a compression bra and reports in vitro stress tests of processed and unprocessed fat cells. METHODS: Clinical bra pressure measurements were conducted on a cohort of 45 patients following lipofilling, reduction mammoplasties and DIEP flaps. Laboratory analysis included cell vitality testing using Resazurin assays of processed and unprocessed fat cells after exposure to mechanical or hyperbaric pressure. RESULTS: Our findings show a mean overall pressure value of the compression bra for all patients of 6.7 ± 5.7 mmHg (range 0-35). Cell processing is superior to sedimentation only regarding fat cell vitality. However, neither mechanical pressure within the specified range nor hyperbaric oxygen exposure significantly affected fat graft survival as measured by Resazurin assays. CONCLUSION: The in vitro measurements showed that it was impossible to harm fat cells with external pressure during lipofilling procedures, regardless of their processing. In the clinical context, the compression bra applied pressure values deceeding the perfusion pressure and may therefore not diminish oxygen supply nor harm the transplanted cells. Therefore, we recommend the use of a compression bra for all lipofilling procedures around the breast. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these evidence-based medicine ratings, please refer to Table of Contents or online Instructions to Authors www.springer.com/00266.

Exosomes from Adipose-Tissue-Derived Stem Cells Induce Proapoptotic Gene Expression in Breast Tumor Cell Line.

Lipofilling is an option for breast reconstruction after tumor resection to avoid the complications of an implant-based reconstruction. Although some concerns exist regarding the oncological safety of tissue rich in mesenchymal stem cells with their proangiogenic and proliferation-supportive properties, there are also reports that adipose-tissue-derived stem cells can exhibit antitumoral properties. We isolated primary adipose-tissue-derived stem cells. Both conditioned medium and exosomes were harvested from the cell culture and used to treat the breast cancer cell line MCF-7. Cell viability, cytotoxicity, and gene expression of MCF-7 cells in response to the indirect co-culture were evaluated. MCF-7 cells incubated with exosomes from adipose-tissue-derived stem cells show reduced cell viability in comparison to MCF-7 cells incubated with adipose-tissue-derived stem-cell-conditioned medium. Expression of proapoptotic genes was upregulated, and expression of antiapoptotic genes was downregulated. The debate about the oncological safety of autologous fat grafting after tumor resection continues. Here, we show that exosomes from adipose-tissue-derived stem cells exhibit some antitumoral properties on breast cancer cell line MCF-7.

The effector program of human CD8 T cells supports tissue remodeling.

CD8 T lymphocytes are classically viewed as cytotoxic T cells. Whether human CD8 T cells can, in parallel, induce a tissue regeneration program is poorly understood. Here, antigen-specific assay systems revealed that human CD8 T cells not only mediated cytotoxicity but also promoted tissue remodeling. Activated CD8 T cells could produce the epidermal growth factor receptor (EGFR)-ligand amphiregulin (AREG) and sensitize epithelial cells for enhanced regeneration potential. Blocking the EGFR or the effector cytokines IFN-γ and TNF could inhibit tissue remodeling. This regenerative program enhanced tumor spheroid and stem cell-mediated organoid growth. Using single-cell gene expression analysis, we identified an AREG+, tissue-resident CD8 T cell population in skin and adipose tissue from patients undergoing abdominal wall or abdominoplasty surgery. These tissue-resident CD8 T cells showed a strong TCR clonal relation to blood PD1+TIGIT+ CD8 T cells with tissue remodeling abilities. These findings may help to understand the complex CD8 biology in tumors and could become relevant for the design of therapeutic T cell products.

Factors influencing the shape, size, symmetry and scar of the nipple-areola complex after bilateral reduction mammoplasty.

BACKGROUND: Asymmetry and scar formation of the nipple-areola complex (NAC) after reduction mammoplasty with periareolar suture are common complications and can significantly affect patient satisfaction. OBJECTIVE: The aim of this study was to investigate possible procedure-specific influencing factors on asymmetry and shape disturbances of the nipple-areola complex to optimize postoperative outcome and thus improve patient satisfaction. METHODS: 78 patients were followed-up after a 5-year period as part of a retrospective cohort study. Objective parameters as areolar diameter, symmetry, scar patterns, dimensions of the breast, and anthropometric measurements were recorded. All patients underwent surgery according to an established treatment algorithm depending on the preoperative measurements. Follow up was 1 week, 6 week, 6 months and 3 years postoperatively. RESULTS: The periareolar suture-technique significantly influenced the symmetry and shape of the NAC. Compared to the intraoperative determined diameter and the postoperative diameter, the net-suture technique showed the highest NAC symmetry and minimal divergence. Patients who underwent Hall-Findlay mammoplasty showed significantly higher rates of asymmetry and deformity of the NAC with teardrop formation in comparison to Lejour mammoplasty. Scar formation was affected by periareolar ruffle formation especially after purse string suture. CONCLUSIONS: Regardless of what reduction mammoplasty techniques and periareolar suturing-technique are used, a tension-free suture of the NAC is crucial for shape, symmetry and scar formation. The net suture technique resulted in significantly higher symmetry of the NAC.

The influence of negative pressure wound therapy on bacterial and fungal growth.

BACKGROUND: The use of negative pressure wound therapy (NPWT) in superinfected wounds is controversial. The mechanism of action is unclear, but recent studies have shown lower atmospheric oxygen levels within the dressing. Therefore, different oxygen-favoring bacteria and fungi might benefit or face impaired thriving conditions. The aim of this in vitro study is to investigate the influence of NPWT on bacterial and fungal growth. METHODS: Salmonella enterica subsp. enterica serovar Typhimurium, Pseudomonas aeruginosa and Candida albicans strains were cultured on concentrated agars and attached to a standard NPWT-device. After 48 hours, colonies were separately harvested from the agar and foam. Optical density (OD) was obtained in order to estimate bacterial loads. RESULTS: For all tested microorganisms, no overall significant differences were found compared to controls. Subanalysis showed lower OD levels from the agar beneath the foam in the NPWT-group. CONCLUSION: NPWT removed bacteria and fungi from the wound surface but accumulation is found within the foam. The use of NPWT showed no influence on bacterial or fungal growth selection. With superinfected wounds, the use of NPWT should thoroughly be evaluated as toxins and virulence factors may not fully be evacuated.

Precise Monitoring of Returning Sensation in Digital-Nerve Lesions by Three-Dimensional Imaging: A Proof-of-Concept Study.

SUMMARY: Digital-nerve lesions result in a loss of tactile sensation reflected by an anesthetic area (AA) at the radial or ulnar aspect of the respective digit. Available tools to monitor the recovery of tactile sense have been criticized for their lack of validity. Precise quantification of AA dynamics by three-dimensional (3D) imaging could serve as an accurate surrogate to monitor recovery after digital-nerve repair. For validation, AAs were marked on digits of healthy volunteers to simulate the AA of an impaired cutaneous innervation. The 3D models were composed from raw images that had been acquired with a 3D camera to precisely quantify relative AA for each digit (3D models, n = 80). Operator properties varied with regard to individual experience in 3D imaging and image processing. In addition, the concept was applied in a clinical case study. Results showed that images taken by experienced photographers were rated as better quality ( P < 0.001) and needed less processing time ( P = 0.020). Quantification of the relative AA was not altered significantly, regardless of experience level of the photographer ( P = 0.425) or image assembler ( P = 0.749). The proposed concept allows precise and reliable surface quantification of digits and can be performed consistently without relevant distortion by lack of examiner experience. Routine 3D imaging of the AA has the great potential to provide visual evidence of various returning states of sensation and to convert sensory nerve recovery into a metric variable with high responsiveness to temporal progress.

Lightweight implants in breast reconstruction.

OBJECTIVE: Since the first use of silicone implants by Cronin in 1962, there have been several attempts to introduce alternative filling materials for breast implants on the market. A promising new development are lightweight implants, whose filler material is one third lighter than conventional silicone gel. While these implants have been used primarily for aesthetic augmentation, a benefit could be expected particularly in post-mastectomy reconstruction. MATERIALS AND METHODS: Since 2019, 92 operations using lightweight implants have been performed at our clinic, 61 of them for breast reconstruction after mastectomy. These have been compared to 92 breast reconstructions using conventional silicone implants. RESULTS: The average volume of the lightweight implants was 30% higher than of the conventional implants (452 ml resp. 347 ml), whereas the implant weight was comparable in both groups (317 g resp. 347 g). Grade 3-4 capsular fibrosis was seen in 6 cases in both groups; revision was required 9 times (lightweight implants) and 7 times (conventional silicone implants) during the follow-up period. DISCUSSION: To our knowledge, this is the first study to investigate the use of lightweight implants in breast reconstruction. With exception of the filler material, the implants used in the two groups were comparable in shape and surface. The inserted lightweight implants had a greater volume but nearly the same weight as the conventional implants and were used in patients with a higher body mass index. Thus, lightweight implants were preferred in patients whose reconstruction required a larger implant volume. CONCLUSION: Lightweight implants are a new alternative for breast reconstruction especially in case that larger implant volume is demanded. The increased complication rate has to be verified in further studies.

Chorioallantoic Membrane Assay at the Cross-Roads of Adipose-Tissue-Derived Stem Cell Research.

With a history of more than 100 years of different applications in various scientific fields, the chicken chorioallantoic membrane (CAM) assay has proven itself to be an exceptional scientific model that meets the requirements of the replacement, reduction, and refinement principle (3R principle). As one of three extraembryonic avian membranes, the CAM is responsible for fetal respiration, metabolism, and protection. The model provides a unique constellation of immunological, vascular, and extracellular properties while being affordable and reliable at the same time. It can be utilized for research purposes in cancer biology, angiogenesis, virology, and toxicology and has recently been used for biochemistry, pharmaceutical research, and stem cell biology. Stem cells and, in particular, mesenchymal stem cells derived from adipose tissue (ADSCs) are emerging subjects for novel therapeutic strategies in the fields of tissue regeneration and personalized medicine. Because of their easy accessibility, differentiation profile, immunomodulatory properties, and cytokine repertoire, ADSCs have already been established for different preclinical applications in the files mentioned above. In this review, we aim to highlight and identify some of the cross-sections for the potential utilization of the CAM model for ADSC studies with a focus on wound healing and tissue engineering, as well as oncological research, e.g., sarcomas. Hereby, the focus lies on the combination of existing evidence and experience of such intersections with a potential utilization of the CAM model for further research on ADSCs.

The effect of radiotherapy on fat engraftment for complete breast reconstruction using lipofilling only.

PURPOSE: Lipofilling has been established as a standard technique for contour enhancement following breast reconstruction. However, there is a paucity in current literature regarding the use of this technique for complete reconstruction of the female breast as an alternative to conventional techniques, such as expander or flap-based procedures. In particular, the influence of pre-operative irradiation for successful reconstruction has rarely been examined in published studies. Here, the authors describe their experience with successful fat injection in pre-radiated breasts in comparison with non-pre-radiated patients. METHODS: In this retrospective study, we examined a total of 95 lipofilling treatments on 26 patients (28 breasts). All of them experienced mastectomy following breast cancer; local breast defects after partial resection of the gland were not included in this study. In total, 47 lipofilling procedures in 12 non-irradiated patients (14 breasts) and 48 procedures in 14 irradiated women (also 14 breasts) were performed. Per session, approximately 297 ± 112 cc of adipose tissue was grafted in group A (no radiotherapy) and approximately 259 ± 93 cc was grafted in group B (radiotherapy). RESULTS: Among the group of women without pre-operative radiation, 71% of breast reconstructions limited to lipofilling only showed constant engraftment of fat tissue with a successful reconstructive result, whereas only 21% of the patients with pre-radiated breasts showed complete reconstruction of the breast with a permanent fat in-growth. CONCLUSION: Preoperative radiotherapy significantly impedes successful completion of breast reconstructions planned only by autologous fat transfer. Patients should be selected individually and carefully for complete breast reconstruction using lipofilling only.

Cell-Enriched Lipotransfer (CELT) Improves Tissue Regeneration and Rejuvenation without Substantial Manipulation of the Adipose Tissue Graft.

The good availability and the large content of adult stem cells in adipose tissue has made it one of the most interesting tissues in regenerative medicine. Although lipofilling is one of the most frequent procedures in plastic surgery, the method still struggles with high absorption rates and volume losses of up to 70%. Therefore, many efforts have been made to optimize liposuction and to process the harvested tissue in order to increase fat graft retention. Because of their immunomodulatory properties, their cytokine secretory activity, and their differentiation potential, enrichment with adipose tissue-derived stem cells was identified as a promising tool to promote transplant survival. Here, we review the important parameters for lipofilling optimization. Finally, we present a new method for the enrichment of lipoaspirate with adipose tissue-derived stem cells and discuss the parameters that contribute to fat graft survival.

Peripheral Nerve Regeneration-Adipose-Tissue-Derived Stem Cells Differentiated by a Three-Step Protocol Promote Neurite Elongation via NGF Secretion.

The lack of supportive Schwann cells in segmental nerve lesions seems to be one cornerstone for the problem of insufficient nerve regeneration. Lately, adipose-tissue-derived stem cells (ASCs) differentiated towards SC (Schwann cell)-like cells seem to fulfill some of the needs for ameliorated nerve recovery. In this study, three differentiation protocols were investigated for their ability to differentiate ASCs from rats into specialized SC phenotypes. The differentiated ASCs (dASCs) were compared for their expressions of neurotrophins (NGF, GDNF, BDNF), myelin markers (MBP, P0), as well as glial-marker proteins (S100, GFAP) by RT-PCR, ELISA, and Western blot. Additionally, the influence of the medium conditioned by dASCs on a neuron-like cell line was evaluated. The dASCs were highly diverse in their expression profiles. One protocol yielded relatively high expression rates of neurotrophins, whereas another protocol induced myelin-marker expression. These results were reproducible when the ASCs were differentiated on surfaces potentially used for nerve guidance conduits. The NGF secretion affected the neurite outgrowth significantly. It remains uncertain what features of these SC-like cells contribute the most to adequate functional recovery during the different phases of nerve recovery. Nevertheless, therapeutic applications should consider these diverse phenotypes as a potential approach for stem-cell-based nerve-injury treatment.

The Effects of Shear Force-Based Processing of Lipoaspirates on White Adipose Tissue and the Differentiation Potential of Adipose Derived Stem Cells.

Autologous lipotransfer is a promising method for tissue regeneration, because white adipose tissue contains a heterogeneous cell population, including mesenchymal stem cells, endothelial cells, immune cells, and adipocytes. In order to improve the outcome, adipose tissue can be processed before application. In this study, we investigated changes caused by mechanical processing. Lipoaspirates were processed using sedimentation, first-time centrifugation, shear-force homogenization, and second-time centrifugation. The average adipocyte size, stromal vascular cell count, and adipocyte depot size were examined histologically at every processing step. In addition, the adipose derived stem cells (ADSCs) were isolated and differentiated osteogenically and adipogenically. While homogenization causes a disruption of adipocyte depots, the shape of the remaining adipocytes is not changed. On average, these adipocytes are smaller than the depot adipocytes, they are surrounded by the ECM, and therefore mechanically more stable. The volume loss of adipocyte depots leads to a significant enrichment of stromal vascular cells such as ADSCs. However, the mechanical processing does not change the potential of the ADSCs to differentiate adipogenically or osteogenically. It thus appears that mechanically processed lipoaspirates are promising for the reparation of even mechanically stressed tissue as that found in nasolabial folds. The changes resulting from the processing correspond more to a filtration of mechanically less stable components than to a manipulation of the tissue.

Implants Versus Lipograft: Analysis of Long-Term Results Following Congenital Breast Asymmetry Correction.

AIMS: Congenital breast asymmetry represents a particular challenge to the classic techniques of plastic surgery given the young age of patients at presentation. This study reviews and compares the long-term results of traditional breast augmentation using silicone implants and the more innovative technique of lipografting. METHODS: To achieve this, we not only captured subjective parameters such as satisfaction with outcome and symmetry, but also objective parameters including breast volume and anthropometric measurements. The objective examination was performed manually and by using the Vectra® H2 photogrammetry scanning system. RESULTS: Differences between patients undergoing either implant augmentation or lipograft were revealed not to be significant with respect to patient satisfaction with surgical outcome (p = 0.55) and symmetry (p = 0.69). Furthermore, a breast symmetry of 93 % was reported in both groups. Likewise, no statistically significant volume difference between the left and right breasts was observed in both groups (p < 0.41). However, lipograft patients needed on average 2.9 procedures to achieve the desired result, compared with 1.3 for implant augmentation. In contrast, patients treated with implant augmentation may require a number of implant changes during their lifetime. CONCLUSION: Both methods may be considered for patients presenting with congenital breast asymmetry. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Surgery of congenital breast asymmetry-which objective parameter influences the subjective satisfaction with long-term results.

PURPOSE: Congenital breast asymmetry is a serious gynecological malformation for affected patients. The condition hits young women in puberty and is associated with socio-esthetic handicap, depression, and psychosexual problems. Surgical treatment is usually early in the patient's lifetime, so a long-term sustainable solution is important. Although postoperative outcome has been evaluated in several studies before, this study is the first to analyze which objective parameters have the greatest influence on subjective satisfaction with long-term results. METHODS: Thirty-four patients diagnosed with congenital breast asymmetry that underwent either lipofilling or implant therapy between the years of 2008 to 2019 were examined. On average, our collective comprised patients seven years after surgery. Data were mainly gathered through manual measurements, patient-reported outcome measures (Breast Q™), and breast volumetry based on 3D scans (Vectra® H2, Canfield Scientific). RESULTS: Among all analyzed parameters, only areolar diameter correlated significantly negatively with the subjective outcome satisfaction of the patient. Regarding the subjective assessment of postoperative satisfaction with similarity of the breasts, again the mean areolar diameter, but also the difference in areolar diameter and breast volume between the right and left breasts correlated significantly negatively. CONCLUSION: Areolar diameter was revealed as being a significant factor influencing subjective long-term satisfaction in breast asymmetry patients. Moreover, 3D volumetry proves to be an effective tool to substantiate subjective patient assessments. Our findings may lead to further improvements to surgical planning and will be expanded in further studies.

Autologous fat grafting for breast reconstruction after breast cancer: a 12-year experience.

PURPOSE: The aim of our study was to examine the surgical outcome and complications (efficiency) as well as the incidence of locoregional recurrence and distant metastases (oncological safety) in patients who underwent autologous fat grafting (AFG) of the breast following breast cancer surgery. METHODS: In our monocentric cohort study, retrospective and prospective data were collected from all consecutive patients who underwent AFG after breast cancer between 2008 and 2020; a total of 93 patients met the inclusion criteria. RESULTS: Our long-term results showed no increase in tumor recurrence and distant metastases in the studied collective when compared to the available literature. We observed 1 local recurrence (1.1%), 2 distant metastases (2.2%), and 1 tumor-related death (1.1%). There was a high degree of patient satisfaction; 67.12% of patients reported adequate satisfaction with autologous fat grafting. CONCLUSION: Currently, to our knowledge, this is the study with the longest follow-up time (mean 6.7 years after AFG and 11.5 years after tumor resection). The results of our clinical study will contribute to improve evidence in the broad field of AFG, adipose stem cell and tumor research. Consistent with our study, the literature review shows a clear tendency of clinical trial results with a low incidence rate of tumor recurrence and metastasis following the use of AFG. AFG seems to be a safe procedure also after breast cancer treatment.

Comparison of skin sensitivity following breast reconstruction with three different techniques: Autologous fat grafting, DIEP flap and expander/implant1.

BACKGROUND: Autologous fat grafting (AFG) has been established over the past two decades as an additive technique during and after breast reconstruction. Complete reconstruction of the breast mound with AFG alone represents an exceptional technique that has been published mostly in case reports or in studies with limited cases.The purpose of this study is to investigate the influence of three different techniques for breast reconstruction on the recovery of skin sensitivity at the reconstructed breast. METHODS: The study included 30 patients after mastectomy following breast cancer. Three groups were examined: A) breast reconstruction by autologous fat grafting (AFG), B) breast reconstruction by deep inferior epigastric artery perforator flap (DIEP) and C) breast reconstruction by expander/implant (TE).Biometric data were compared; sensitivity tests were performed using Semmes-Weinstein monofilaments.The non-operated, healthy contralateral breasts of the patients were used as a reference. RESULTS: While the traditional reconstruction techniques by microsurgical anastomosed perforator flap or expander/implant showed a strongly decreased or completely missing sensitivity of the skin, the tests after reconstruction by AFG represented high values of sensory recovery, which came close to the reference group of non-operated breasts. CONCLUSION: To our knowledge, this is the first study to compare skin sensitivity after AFG-based reconstruction to established techniques for breast reconstruction. We could demonstrate in a limited group of patients, that breast reconstruction by autologous fat grafting can achieve higher values of skin sensitivity compared to traditional techniques.

Adipose Tissue-Derived Stem Cell Yield Depends on Isolation Protocol and Cell Counting Method.

In plastic surgery, lipofilling is a frequent procedure. Unsatisfactory vascularization and impaired cell vitality can lead to unpredictable take rates in the fat graft. The proliferation and neovascularization inducing properties of adipose tissue-derived stem cells may contribute to solve this problem. Therefore, the enrichment of fat grafts with stem cells is studied intensively. However, it is difficult to compare these studies because many factors-often not precisely described-are influencing the results. Our study summarizes some factors which influence the cell yield like harvesting, isolation procedure and quantification. Stem cells were isolated after liposuction. Quantification was done using a cell chamber, colony counting, or flow cytometry with changes to one parameter, only, for each comparison. Quantification of cells isolated after liposuction at the same harvesting site from the same patient can vary greatly depending on the details of the isolation protocol and the method of quantification. Cell yield can be influenced strongly by many factors. Therefore, a comparison of different studies should be handled with care.

Facial Rejuvenation with Concentrated Lipograft-A 12 Month Follow-Up Study.

Lipofilling is a popular technique to treat volume loss in aging patients. The isolated adipose tissue is composed of adipocytes and stromal vascular fraction cells, which include adipose-derived stem cells (ASC). We hypothesize that the patient's wrinkle severity scale (WSS) and patient's satisfaction on the global aesthetic improvement scale (GAIS) can be improved after using concentrated lipoaspirate. Fourteen patients (54 years ± 11.09 years) with volume loss in the midface area underwent waterjet-assisted liposuction (Human Med AG, Schwerin, Germany). Fat was centrifuged in an ACP Double Syringe (Arthrex GmbH, Munich, Germany) using Rotofix 32A centrifuge (Andreas Hettich, GmbH & Co.KG, Tuttlingen, Germany). Homogenization was performed using the double syringe and a 1.4 mm female-female luerlock connector. After a second centrifugation, patients received periorbital (PO) and nasolabial (NL) lipografting. ASC count was performed after enzymatical digestion. Vitality of cells was assessed using a resazurin assay. During long-term follow up (12 months, n = 10), we found a high patient's satisfaction (GAIS 1+/-0.52) and a good improvement of the WSS during short- and long-term follow-up. The ASC count of processed lipoaspirate was 2.1-fold higher than of unprocessed lipoaspirate (p < 0.001). The difference of ASC in sedimented and simply centrifuged lipoaspirate was also significant (p < 0.05). Facial rejuvenation with concentrated fat graft offers good results concerning objective aesthetic outcome and patient's satisfaction.