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Shaaban et al. Plast Aesthet Res 2023;10:12 https://dx.doi.org/10.20517/2347-9264.2022.91 Page 9 of 16

research has investigated the underlying mechanisms behind these benefits. A recent in vitro study utilizing
adipose-derived stem cells demonstrated secretome-mediated reversal of pro-fibrotic cellular and molecular
changes in dysfunctional fibroblasts, and proposed that this is the process by which autologous fat transfer
[119]
softens and reduces capsular fibrosis . Animal models of capsular contracture have shown that autologous
fat transfer during implant placement prevents the formation of capsular contracture by reducing tissue
inflammation and decreasing collagen content, density, and fiber alignment of the capsular tissue [117,118] .

There is also growing clinical evidence identifying autologous fat transfer's role in reducing the risk of
[120]
capsular contracture . One study showed that it can be a practical treatment strategy for symptomatic
capsular contracture by mitigating fibrotic damage, reducing severity, and alleviating symptoms to the
extent that corrective surgery was circumvented . Another showed that autologous fat transfer could
[121]
prevent the recurrence of capsular contracture when serially administered in severe cases of capsular
contracture following implant removal and partial capsulectomy .
[122]

The benefits of autologous fat transfer are even more pronounced when implant-based breast
reconstruction involves patients treated with radiation therapy. It is well-documented that there is an
increased risk of capsular contracture in these patients [123,124] . The benefits were documented for the first
time in 2009 when a study showed that serial autologous fat transfer could improve outcomes and reduce
[125]
complications of implant-based breast reconstruction for patients with irradiated breasts . Subsequent
studies demonstrated that autologous fat transfer before implant placement can improve healing, increase
soft tissue stability, and reduce radiation-related complications [126-128] . When used to treat post-irradiation
capsular contracture, autologous fat transfer was able to decrease long-term symptom rates and reduce the
need for follow-up surgery [129,130] . Although beneficial in many respects, autologous fat transfer is not
without limitations. In one study, it was shown to have no protective effect as a prophylactic agent when
used to prevent radiation-induced capsular contracture . Additional research is needed to better
[131]
understand the value and restrictions of using autologous fat transfer for the prevention and treatment of
capsular contracture after implant placement.

RESEARCH ON THE HORIZON
Fat grafting is generally considered a versatile and useful method for creating autologous volume despite the
aforementioned challenges regarding unpredictable retention. However, past research on total breast
reconstruction with fat grafting lacks a compelling argument to convince most reconstructive surgeons to
perform it regularly for breast reconstruction. There exists a need for robust and convincing data to
demonstrate the superiority of fat grafting in terms of patient satisfaction. In addition, more studies are
needed that address retention, cryopreservation, safety, and efficacy. It is yet to be determined if this
evidence alone will encourage this technique. Other factors, such as reimbursement and feasibility, do play
an important role. To ease the burden incurred by multiple harvesting procedures, research is underway to
evaluate cryopreserved fat for future secondary procedures or use biologic adjuncts to improve primary fat
grafting retention.

To date, Level I/II evidence suggests cryopreserved lipoaspirate has fair clinical outcomes, primarily when
used for small volumization in the face [132,133] . When used in larger volumes for gluteal augmentation, one
case study describes outcomes in a 42-year-old male as satisfactory using abdominal adipose cryopreserved
[134]
at -20 ˚C for 3 months . Therefore, secondary touch-up procedures in the breast following reconstruction
may be feasible. However, significantly more work in procedure standardization is required as others have
noted potential clinical risks associated with oil cyst accumulation from reduced tissue viability from
storage and lack of validation towards sterility, potentially causing infection such as what occurred in a
[135]