Abstract

Background: Lipofilling has become a widely used procedure in breast delayed reconstruction, after mastectomy, or breast conservative therapy, or autologous flap reconstruction. Main limitation is high reabsorption rate and local complications. The aim of this study is to evaluate the possible enhancement of the lipoinjectate to overcome these limitations. Methods: Between years 2017 and 2021, patients with PRP-enhanced lipofilling (Coleman technique) for correction (delayed) of different deformities after different surgical procedures used for breast cancer, (+-6 months after radiotherapy). Results: We performed the technique Platelet Rich Plasma enhanced lipoinjection after different surgical procedures used for breast cancer for 50 females, in which 20 patients underwent previous Breast Conservative therapy, 14 patients underwent modified radical mastectomy, and 16 patients had autologous flap reconstruction. Duration of operation 60-260 minutes, oil cysts 4%, fat necrosis 18%, microcalcifiaction 2%, absorption rate 31%, patient satisfaction (very satisfied) 42%. Conclusion: Although further investigations at the cellular level are needed, the results support the fact that PRP enhances the lipoinjectate subjectively, with lesser reabsorption rate and complications.

1. Introduction

Treatment of breast cancer should always be performed in a multidisciplinary approach. ¹ Restoring an acceptable appearance after breast cancer surgery has become an integral part of the treatment process. ² Unfortunately not only modified radical mastectomy, but breast conserving therapy still leads to breast deformity in most patients. The deformity is progressive and deteriorates with time as a result of breast irradiation (radiodermatitis), ³ Recently, breast reconstruction using fat transfer has become the standard of care in patients which underwent mastectomy, ⁴ for volume augmentation with serial fat grafting. ⁵ There have been reports of complete breast reconstruction after mastectomy being accomplished with good results, and an immediate nipple reconstruction may be performed, ⁴ and also to restore the thickness of mastectomy skin flaps. ⁶ Fat transfer has been widely used after BCS, ⁷ where it aims to recover shape, volume, defects, contour ordeals, challenging irregularities and asymmetry after surgical approach; as a primary reconstruction means and also as an adjunct to other techniques. ⁸ Providing this solution of lipofilling, has showed eventually a decline in contralateral esthetic surgeries, ⁹ specially for breast remodeling in small breasts, ⁸ and in tumors located in upper and inner quadrants, and at the junction of the upper quadrants of the breast and décolleté area. ¹⁰ Thus improving also the shape, the projection, the feel and the silhouette of the breast, with better defined cleavage when applied in inner quadrants. ⁴ Its advocated specially where volume deficiencies occur at sites which are not accessible for implants, or for other local corrections, and can be combined with different autologous flap reconstruction as a great adjunct tool. ⁶ A scintillating aspect is the regenerative aspect, ¹¹ as the resultant radiodermatitis deformity is progressive and deteriorates with time, causing a paradigm shift in the treatment of radiodamaged tissue, ¹² and improving skin tropism. ^{6, 13} Lipofilling technique dates to over a century ago. ¹⁴ Lipofilling is the process of relocating autologous fat to change/restore the shape, volume, consistency and profile of tissues. ¹² Fat grafting involving the harvesting, processing, and infiltration of fat at the same procedure. ¹⁰ Serving the aim of reconstructing, rejuvenating and regeneration body features. Fat grafting has safety profile, no hypersensitivity reaction and no odds of rejection, no autoimmune/autoinflammatory syndrome, ^{15, 16} and is a mini-invasive and low-traumatic, patient friendly technique providing new personalized reconstructive options with excellent aesthetic outcome. ^{17, 18} an easy simple procedure that gave results of a high level of patient satisfaction, thus improving the quality of the patient's life. The adipose tissue is ideal soft tissue filler owing to its abundant limitless sources, natural texture, biocompatible, inexpensive and has no disease transmission, with the plus of removal of undesirable fat from other regions is an additional benefit. ⁴ The aim of this study was to evaluate the delayed platelet rich plasma enhancement lipomodelling used for correction of deformities after different surgical procedures for breast cancer regarding efficacy of esthetic outcome and patient satisfaction.

2. Patients and Methods

Fifty female patients who were admitted to the department of Surgery, Medical Research Institute, Alexandria University, from 2017 to 2021, and scheduled to PRP enhanced lipofilling after being operated upon breast cancer: by modified radical mastectomy without previous reconstruction (done with the aim of PRP enriched lipofilling is to prepare the site for future breast reconstruction), patients after previous oncoplastic autologous flap reconstruction techniques, for augmentation and correction of defect or deformities purposes, patients after BCS with tissue defect and/or deformities. Delayed Platelet rich plasma enhanced lipofilling is approached at least six months after completion of radiotherapy for rejuvenation and regeneration of unfortunate effects of radiotherapy (radiodermatitis). Patients who have had inadequate donor sites or on a weight reduction regimen, or with general comorbidities (that were a contraindication to general anaesthesia), or were with vasospastic conditions, or were smoking, or were with current use of immumosuppressant drugs; were excluded from the study.

Institutional research Committee approved the protocol before the study started. The study was explained to prospective patients and written informed consent was obtained before study entry.

Data were fed to the computer and analyzed using IBM SPSS software package version 20.0. (Armonk, NY: IBM Corp) Qualitative data were described using number and percent. The Kolmogorov-Smirnov test was used to verify the normality of distribution. Quantitative data were described using range (minimum and maximum), mean, standard deviation and median. Significance of the obtained results was judged at the 5% level.

All patients included in this study were subjected to complete history taking: with emphasis on previous chemo and radiotherapy, and on evidences of metastatic manifestations of malignancy, full clinical examination, lab investigations and radiological investigations. In the cases which undertook radiotherapy, patients underwent delayed lipomodelling enhanced by platelet rich plasma at least 6 months after completion of radiotherapy, while patients who did not, had the procedure after completion of chemotherapy.

Pre-operative drawings: Patients were examined in the upright standing position. There are pre-operative (and post-operative) photographs taken to assess esthetic outcome. Both donor and recipient were marked. Donor areas were the areas where fat is available to a sufficient extent: abdomen and lateral thighs and hips. Abdomen was the most common site. The second site was the inside of the thighs (inner thigh area), but the outer thigh and flank were preferred; as fat appears here to be more resilient to weight fluctuation.

Operative technique: Lipomodelling enhanced by Platelet Rich Plasma was performed under general anesthesia. At present, the technique used by the majority of surgeons for lipofilling was published in 1995 by Coleman. Coleman's atraumatic technique is the most frequently used technique worldwide. ³ This technique consisted of fat harvesting, fat processing and lipoinjection. ¹⁹ We used local infiltration by a solution of lidocaine 0.5% with adrenaline (1:80000 – 1:100000), diluted in sodium chloride 0.9% or Ringer's solution, to prepare the donor site. ¹⁸

Lipofilling with autografted PRP enhanced fat: Fat harvesting: Fat harvesting was done by a blunt-tipped liposuction cannula (2mm) with slight low negative pressure of 50cc Luer Lock syringe, after infiltration of Klein's solution, within the subcutaneous tissue. ¹⁸ Fat processing processing/preparation of fat: The processing was done by centrifuging under aseptic technique at 3000 rpm for 3 minutes. After the centrifugation, the middle layer was the target layer. ¹⁹ PRP preparation: ^{17, 20} PRP preparation was under complete strict aseptic technique. A specific amount of citrated fresh venous blood was sampled from the same fat tissue donor patient. A final volume of 3ml of PRP is delivered directly. Sample collection: 14 ml of venous blood collected in vaccutainer tubes containing sodium citrate 3.2% anticoagulant (blood:citrate ratio 9:1) The tubes were centrifuged for short time soft spin. The supernatant for plasma and the buffy coat layer containing the platelets were separated from the cells using sterile pasteurs and then transferred to sterile plain tubes (without anticoagulant). The tubes were then centrifuged high speed; hard spin (centrifugation spin). At the bottom of the tube pellets were formed; where the lower part is PRP. The platelet rich plasma obtained is added to the prepared lipoaspirate. We mixed 0.5 ml of PRP with 50 ml of centrifuged fat tissue (1%). ²¹ The mixture was left for few minutes of 4-5 minutes. The purified body fat mixed with PRP was put in 1ml syringes. Lipoijnection: The processed fat tissue injection was performed using the "Gentle technique”. ³ The middle layer of the cellular component after enrichment with the platelet rich plasma, was transferred to a 1cc or 3cc Luer-Lock syringe by blunt-tipped small caliber infiltration cannula (1-2mm). ⁶ Fat was injected using a blunt Coleman infiltration cannula connected to a 1ml syringe, with a retrograde, radial, multi-layered and multi-diectional technique. ¹⁸ Also the PRP enriched fat could/was sometimes injected by riggotomy technique in the cases with deforming tight scar tissue. ²² The skin is closed with non-absorbable simple suture material. ⁶ In BCS, injection at the subcutaneous layer was done, also glandular defects were corrected. After MRM without or with previous reconstruction (musculocutaneous flap), injected at the subcutaneous layer; thickening the flaps. If nipple-areolar reconstruction, or riggotomies were needed, the procedure were done accordingly. ²³

Post-operative follow-up: Simple dressings and steristrips were used on the grafted area and compressive dressings at the donor site (to prevent heamatoma formation). Early wound inspection after 48 hours was done. In this study, esthetic outcomes, patient satisfaction, and complications were evaluated after completion of the procedure, at several post operative timings: at 1 week, and at 3, 6 and 12 months. Esthetic evaluation was made by (subjective) clinical examination. Radiological assessment was by ultrasonography/mammography at 6 and 12 months after PRP enriched lipofilling procedure. The esthetic outcome evaluation was by a panel of two surgeons experienced in advanced oncoplastic procedures, who took regard of the pre-operative and post-operative photographic records taken. A three month assessment was made to examine the recipient and donor sites and plan for further staged procedures. Absorption rate was subjectively evaluated after 3, 6 and 12 months and planning for further staged procedures was considered accordingly. Patient and surgeon satisfaction were evaluated after 6 months by a questionnaire.

3. Results

The aim of this study was to evaluate the delayed PRP enhanced lipomodelling used for correction of deformities after different surgical procedures for breast cancer regarding efficacy of esthetic outcome and patient satisfaction in fifty female patients. The female patients were of age between 42 years old and 56 years old, with a mean BMI 30, as shown in Table 1. There were three main groups in this study as shown in Table 2. GroupI: 20 patients who underwent previous breast conservative therapy, GroupII: 14 patients who underwent previous modified radical mastectomy, and GroupIII: 16 patients who underwent sessions of PRP enhanced lipofilling plus autologous flap reconstruction. Twenty two patients underwent modified radical mastectomy, while twenty cases underwent breast conservative therapy, while six patients underwent nipple sparing mastectomy, and two cases only underwent skin sparing mastectomy. In GroupI: one patient had underwent oncoplastic technique of round block, one patient underwent Grizotti technique,, eight patients underwent glandular flap, five patients underwent lateral mammoplasty, two patients underwent medial mammoplasty, and three cases underwent therapeutic inferior pedicle reduction mammoplasty. There were three main groups in this study as shown in Table 2. GroupI: 20 patients who underwent previous breast conservative therapy, GroupII: 14 patients who underwent previous modified radical mastectomy, and GroupIII: 16 patients who underwent sessions of PRP enhanced lipofilling plus autologous flap reconstruction. Twenty two patients underwent modified radical mastectomy, while twenty cases underwent breast conservative therapy, while six patients underwent nipple sparing mastectomy, and two cases only underwent skin sparing mastectomy. In GroupI: one patient had underwent oncoplastic technique of round block, one patient underwent Grizotti technique, eight patients underwent glandular flap, five patients underwent lateral mammoplasty, two patients underwent medial mammoplasty, and three cases underwent therapeutic inferior pedicle reduction mammoplasty.

The time span between the different Groups in minutes were variable (Table 3), where in GroupI was of average 80 minutes, in GroupII was average of 120 minutes and in GroupIII was average of 180 minutes. The amount of fat harvested per session for each patient is variable. In GroupI: the amount of fat harvested was in the range of 160 to 900 grams (mean 345 grams). While in GroupII was 220 to 1100 grams (mean 613 grams). While in GroupIII: was 170-1000 grams (mean 503 grams). The donor site (Table 3) in our patients was mainly from the abdomen, thighs, or both. The abdomen provided for 53% of the patients while the thighs alone provided for 13 patients, and both the abdomen and thighs provided for 11% of the patients. This harvested fat was processed according to Coleman's technique producing variable amount of fat to be lipoinjected (Table 3). The amount of fat injected in GroupI: was in the range of 80 to 250 grams (mean 144 grams). While in GroupII was 100 to 470 grams (mean 210 grams). While in GroupIII: was 60-370 grams (mean 177 grams). In Group I fifteen patients underwent one session of PRP enhanced lipofilling, and five patients underwent two sessions. In GroupII: seven patients underwent one session and one patient underwent two sessions and six patients underwent three sessions. In GroupIII: thirteen patients underwent one session of PRP enhanced lipofilling with their auotologous flap reconstruction while two patients underwent another additional session (after her first session of PRP enhanced lipofilling and autologous fat reconstruction), and one patient needed a further third session of PRP enhanced lipofilling. The interval between the sessions was in months. In GroupI the interval was three months in between the sessions. In GroupII, the interval was three months in between the sessions and there was one case in which the interval was six months. In GroupIII the interval was three months for a case, another case the interval was six months, and another case the interval was six months in between the sessions. The repetition of sessions (Table 3) needed patients to be complaint. Some patients did not need repetitive sessions, those who did need according to the Surgeons panel and the patients level of satisfaction; not all accepted to repeat PRP enhanced lipofilling sessions. Two patients in GroupII refused to, two other patients refused too in Group III.

The recipient site complications (Table 4), in GroupI included one case of ecchymosis in the breast, in GroupII; one case of ecchymosis in the breast, while GroupIII three cases of ecchymosis in the breast. There were no incidence of seroma, infection, chronic pain, etc… Radiological follow up revealed possible complications like microcalcifications, oil cyst formation and fat necrosis. In GroupI: none were discovered, while in GroupII three cases showed fat necrosis, and in GroupIII: 1 case showed microcalcification, 2 cases showed oil cyst, and 6 cases showed fat necrosis. The absorption rate after 6 months in the 3 groups varied after PRP enhanced lipofilling. In GroupI: 20-60% (mean 29.75 +/-9.52). In GroupII: 25-40% (mean 31.79 +/-4.64). In GroupIII: 20-50% (mean 32.50 +/-8.76). The subjective evaluation (Table 5) by the two Surgeons (Doctor Panel); resulted in GroupI: 11 patients with Excellent results, 7 patients with Good result, 2 patients with Fair results, and none were Insufficient. While in GroupII: 3 patients with Excellent results, 8 patients with Good result, 2 patients with Fair results, and 1 was Insufficient. While in GroupIII: 4 patients with Excellent results, 9 patients with Good result, 2 patients with Fair results, and 1 was Insufficient. The subjective evaluation by the Patient herself (Table 5); was in the assortment between Very Satisfied, Satisfied, Very Unsatisfied, Unsatisfied. In GroupI: 55% were very satisfied, 35% were satisfied, 5% were very unsatisfied, and 5% were very unsatisfied. In GroupII: 35% were very satisfied, 28% were satisfied, 14% were very unsatisfied, and 21% were very unsatisfied. In GroupIII: 31% were very satisfied, 50% were satisfied, none were very unsatisfied, and 18% were very unsatisfied. The patients were also asked KNUH questionnaire.

4. Discussion

In our study, PRP enriched lipofilling were carried out on fifty female patients operated for breast cancer. Group I: breast conservative surgery (BCS) were twenty female patients, Group II: were mastectomy were fourteen female patients, Group III: were mastectomy+autologous latissimus dorsi flap, sixteen female patients. In our study, PRP enriched lipomodelling offered several indications even in the same session undertaken: contour remodeling 50%, symmetrization 38%, postsurgical defect correction 32%, complete breast reconstruction 13%. A systematic literature review looked into all international articles published between 2007 and 2018 on Medline (PubMed). Several authors shared their experience in PRP enriched lipofilling in breast surgeries; such as Tamimi et al. ²⁶, Mazzocca et al. ²⁷, Araki et al. ²⁸, Bausset et al. ²⁹ Ogundipe et al. ³⁰, Arora et al. ³¹, Yin et al. ³², Slitcher et al. ³³, Kahn et al. ³⁴, Anitua et al., The review by Serra-Mestre et al. ³⁵ aimed to assess the efficacy of PRP mixed fat grafting as a prosurvival strategy for fat grafts. A bibliographic review of the role played by PRP as a prosurvival strategy of autologous fat grafts was conducted. The search for articles was performed in January 2014 after access to the electronic databases of the Cochrane Central Register of Controlled Trials (CENTRAL) and the U.S. National Library of Medicine (MEDLINE) was obtained. ²⁰ In our study's technique, we kept in mind that the survival of fat cell grafts depends on the technique used to harvest and inject them into the receiving site. As mentioned in the methodology we used the atraumatic and low pressure technique described by Coleman; which has been proven to be successful in cosmetic surgery, for breast reconstructive surgery. In our study, the processed fat tissue injection was performed using the "Gentle technique” based on a slow and gentle injection implanting linear deposits of fat graft in the supra-fascial, retro-glandular and intra-glandular space. When the reconstruction included auotologous latissimus dorsi flap, the PRP enhanced lipoaspirate was injected directly into the muscle. The autologous latissimus dorsi (LD) flap was either (previously) immediate LD flap reconstruction or was delayed LD flap reconstruction; in which the LD flap and lipomodelling were done in the same setting. Also, subcutaneous infiltration improves the contour while intraparenchymal injection enhances the projection of the breast. Riggotomy was done in the cases with deforming tight scar tissue. In such circumstance there was no room for a fat PRP enriched graft, therefore the scar needed to be broken up or removed. If the scar internal scar tissue was to be excised; a large empty space will be created that will not support a fat PRP enriched graft. Instead, the scar was loosened by puncturing it with multiple passages of fine needle. The tiny spaces created by the needle pricks became the sites for the placement of the small graft aliquots. Thus a scar cicatrix was loosened and converted into a large matrix acting as a scaffold for receiving a PRP enriched fat graft. The autologous fat transplant has been enhanced by platelet rich plasma from the same donor during the same operating setting as on spot immediate procedure. PRP preparation was under complete strict aseptic technique from a fresh venous blood was sampled in vaccutainer tube. The tubes were centrifuged slow spin for short time soft spin. The supernatant for plasma and the buffy coat layer containing the platelets were separated from the cells using sterile pasteurs and then transferred to sterile plain tubes. The tubes were then centrifuged high speed; hard spin (centrifugation spin). The platelet rich plasma obtained is added to the prepared lipoaspirate. We mixed 0.5 ml of PRP with 50 ml of centrifuged fat tissue (1%). The mixture was left for few minutes of 4-5 minutes. The middle layer of the cellular component of the harvested fat, after enrichment with the platelet rich plasma, was transferred to a 1cc or 3cc Luer-Lock syringe and prepared for injection by blunt-tipped small caliber infiltration cannula (1-2mm). The purified body fat mixed with PRP was put in 1ml syringes. In our study we used a small gauge 2mml blunt tipped cannulas were used to reduce trauma to the recipient site thus decreasing bleeding and heamatoma formation. The diameter of the graft has impact on survival. Care was taken to avoid vascular damage or intravascular injections. Pretunneling was created for the PRP enhanced fat layering on different planes injection technique to optimize the vascular access to the post-transplant. Several layers of multiple tunnels were laid down to increase the contact surface between the receiving tissue and the transplanted injected mixture; this technique is of fundamental importance to allow each layer deposited to survive by diffusion during the few days necessary for growth of blood vessels, which will nourish the transplant permanently. Injection is done on withdrawal and retrograde. The injected network was honeycomb radiating fan like pattern lines on multiple levels and multiple directions, in multiple small volumes was done; microdroplet injection. These small pulses ensure the maximum number of adipocytes to be in close proximity to the recipient tissue to establish source of blood supply. This was preferred over a single injection, to overcome the vascular diffusion defect which occurs more centrally (perfusion starts at the periphery). The volume of PRP enhanced fat injected varies from 0.2ml per pass/2-3ml per tunnel. ³⁶ In a systematic literature review looked into all international articles published between 2007 and 2018 on Medline (PubMed), showed that the preparation of PRP was on whole, non-anticoagulated blood collection in a citrated tube; first centrifugation (soft spin, then a second centrifugation (hard spin). ²⁰ Cervelli et al. ³⁷ maintain that a major concentration of platelet-rich plasma added to purified fat (platelet-rich plasma at 33%, platelet-rich plasma:fat ratio of 1:2) is superior to fat grafting alone. ³⁸ Most of the studies analyzed in this review indicated a potential prosurvival effect of PRP on the fat when suitable PRP concentrations were used. Clinically, the concentration that appears to obtain the most favorable results is 0.4 to 0.5 ml of PRP per each milliliter of fat (1:2 ratio). Mazzocca et al. ²⁷ concluded that the appropriate protocol preparation for a PRP production with respect to the required clinical effect is 3200 RPM for 15 min. ²⁰ Eppley et al. ³⁹ reported that platelet-rich plasma growth factors stimulate endothelial cells near their application site, favoring proliferation and formation of new capillaries. Moreover, in an in vitro study, Hu et al. ⁴⁰ concluded that platelet rich plasma is a potential contributor in possibly starting the process of angiogenesis, recruiting the endothelial cells that line blood vessel. ³⁸ Several reports have adjunctively demonstrated that PRP increases ASC proliferation. Cervelli et al. ⁴¹ Van Pham and colleagues obtained similar results in the proliferation assay. ¹⁷ Insufficient neovascularization was the main limitation for fat survival. In a study by Xiong, et al., ²¹ showed that PRP is rich in angiogenic growth factors, and inhibit the apoptosis of adipocytes and preadipocytes. In our study, the mean follow duration was 14.52 ± 5.95 months, the minimum being 6 months and the maximum 24 months. In our study, the mean amount of fat harvested was 471.0± 250.21 ml, while the amount of pure fat (enhanced with PRP) injected was 173.30 ± 79.05. The mean amount of fat harvested in Group I was 345.50 ± 168.91 ml, while in Group II: was 613.57 ± 259.25ml, and in Group III: was 503.13 ± 262.77 ml. The mean amount of pure fat (PRP enhanced) injected in Group I was 144.50 ± 37.73 ml, while in Group II: was 210.0 ± 107.06 ml, and in Group III: was 177.19 ± 79.37 ml. The mean amount of fat harvested in first session 497.43 ± 251.95 ml, while pure amount of fat injected was 180.43 ± 81.04ml. In second session amount of fat harvested 462.60 ± 230.82 ml, while amount of pure fat (enhanced with PRP) was 167.80 ± 65.08 ml. In third session 213.90 ± 105.95 ml, while amount of pure fat (PRP enhanced) injected was 77.50 ± 58.75 ml. Gentile et al. ⁴² in a study of total 50 patients with breast soft tissue defects. Fat grafting combined with PRP significantly improved maintenance of breast volume in women with breast soft tissue defects. In another study conducted by Cervelli et al. ³⁷, the effects of fat grafting plus PRP on 13 patients with breast soft tissue defects compared with 13 SVF-enhanced autologous fat graft-treated patients were evaluated. Patients treated with PRP in combination with fat grafting showed 69% maintenance of contour restoration, while another group yielded 39% maintenance. In a case series by Gentile, et al. ⁴², supplementation of autologous fat grafts with PRP improved breast soft-tissue defects, compared with centrifuged fat grafting alone. Salgarello et al., ³⁸ with achievement of satisfactory results. In their first study, Gentile et al. ⁴⁴ compared the percentage of volume maintenance, had fat injected according to the Coleman method. In their study, the percentages of volume maintenance were 63 % in the patients treated with SVF-FG, 69 % in the patients treated with PRP and FG combined, and 39 % in the group of patients treated with fat alone. The same authors treated 100 patients with breast soft tissue defects, applying fat grafting alone to 50 patients and a combination of PRP and fat grafting at a 1:2 ratio (0.5 ml PRP for each 1 ml of fat) to the other 50. After 1 year of follow-up the group treated with PRP obtained a graft maintenance of 69 % compared with 39 % in the control group (p\0.0001). ³⁵ This technique can improve skin quality in cases of scarring or radiotherapy outcomes. In some cases, it is possible to give coverage to breast implants and restore residual volume defects. In cases of breast hypoplasia, we can restore the volume, in repeated treatments, to obtain a natural result, with no visible scars. In particular, this is an important advantage in young patients. ⁴⁵ The main and most irritative drawback of lipofilling was injected fat resorption, a common disadvantage of lipofilling, leading to either dissatisfaction or repetitive sessions. After enhancement of grafted fat with PRP, the mean rate of reabsorption was 31.20 ± 8.12 after six months; measured subjectively, by the patient and the Surgeon. The minimum rate was 20% and the maximum was 40%. This drawback was addressed by repeating PRP enhanced lipofilling. The minimum interval in months between repeated sessions was 3 months and the maximum was 10 months. 30% of patients needed more than one session, 25% were from Group I, 50% were from Group II, 18.8% were from Group III. The interval between the sessions was for the aim to allow inter-procedural healing and the maximum volume resorption to occur before subjective assessment. As the factors responsible for graft success are enclosed within the frame of efficient standard technique, and fat graft survival. The technique undertaken was persuaded perfected on the footsteps of the well-established gentle technique by Coleman. The hostile fat graft survival factor, which is under the mercy of rebound inflammatory response, deficient blood supply in the vicinity of the graft, and the nutrition plausible availability; preceding angiogenesis. With the elebaorate explanation of the added PRP's potential, the graft survival in quantity and quality is aspired to overcome those rebellious factors. In 2013, the same authors used ultrasound, magnetic resonance imaging (MRI), and mammography to evaluate the radiologic findings for 24 breasts subjected to lipofilling plus PRP procedures. The authors found that the average resorption percentage of the injected volume was 15.36% at 6 months and 28.23% at 12 months after the last lipofilling session. Oil cysts after 12 months were present in 45.83 % of the patients when breast ultrasound was performed and in 4.17% of the patients when MRI was used. The cytosteatonecrotic areas at 12 months were increased on ultrasound (12.5%) and even more on the MRI scans (16.67%). Using mammography, the authors found the macrocalcification rate to be 12.5 % and the microcalcification rate to be 20.83 %. Three of the calcifications were benign and two were classified as clustered microcalcifications. ⁴⁶ In our study, in the recipient site, there was radiological findings microcalcification, oil cyst formation, and fat necrosis were found. Microcalcification was found only in Group III; as 2%. Oil cyst formation was found only in Group III; as 4%. Fat necrosis was found in Group II; as 21.4%, and in Group III; as 18%. In retrospective study by Salgarello et al, investigated the rate of fat necrosis at regular postoperative breast ultrasound as an objective parameter to evaluate the effect on fat graft take using the two compared methods. ³⁸ In 2013, the same authors used ultrasound, magnetic resonance imaging (MRI), and mammography to evaluate the radiologic findings for 24 breasts subjected to lipofilling plus PRP procedures. The authors found that the average resorption percentage of the injected volume was 15.36% at 6 months and 28.23% at 12 months after the last lipofilling session. Oil cysts after 12 months were present in 45.83 %of the patients when breast ultrasound was performed and in 4.17% of the patients when MRI was used. The cytosteatonecrotic areas at 12 months were increased on ultrasound (12.5%) and even more on the MRI scans (16.67%). Using mammography, the authors found the macrocalcification rate to be 12.5% and the microcalcification rate to be 20.83%. Three of the calcifications were benign and two were classified as clustered microcalcifications. ³⁵ In 2013, Cervelli et al. ⁴⁸ compared the results obtained with the correction of soft tissue defects The authors concluded that lower absorption rates were obtained using higher concentrations. ³⁵ Salgarello et al. ³⁸ compared the results between 17 patients treated with PRP at 10 % plus fat grafting (PRP-FG) at a mean of 120 ml (range, 25-231 ml) per session and 25 patients receiving a mean of 115 ml (range, 21-169 ml) of FG alone using the Coleman technique. The authors found no significant differences in the fat necrosis rate measured with ultrasound, in the number of sessions needed to correct the defects, nor in measurements of the clinical outcomes ^{35, 38} In our study; satisfaction is valued as patient satisfaction and Surgeon panel satisfaction. Surgeon satisfaction was evaluated by two different surgeons; by clinical examination and from the photographic records of the patients before and after each procedure (excellent, good, fair, and insufficient). While patient satisfaction was documented by a questionnaire (KNUH breast reconstruction satisfaction questionnaire) fulfilled by each patient, to reach the conclusion satisfaction (very satisfied, satisfies, unsatisfied, very unsatisfied). Consistency, shape, sensitivity, quality of skin and irregularities of the breast. ⁴² Centrifugation of the lipoaspirate; combined with platelet-rich plasma. Platelet-rich plasma has no impact on the diagnostic images but improves lipofilling results and reduces the resorption rate, increasing fat graft survival. ^{46, 47, 48, 49} One of the main limitations in evaluating the clinical effects of PRP is the fact that many different protocols have been used for its preparation. Currently, various platelet separation processors are commercially available, and protocols with different centrifugation speeds and times have been applied. Also several automated devices are designed to sample and process the making of PRP; giving probable variations at platelet cellular level; needing further evaluation on the count and quality of PRP per ml. We preferred activation of grafted PRP in vivo for no preceding platelet-activation loss, while several authors advocate activation prior to injection. ³⁵ Compared with breast reconstruction using implants of the same size, augmentation with PRP mixed with fat tissue resulted in a lower height but a more natural contour and softness of the breasts. All the patients were satisfied with the resulting texture, softness, and contour, and MRI confirmed maintenance of the restoration. ⁴² Most of the studies analyzed in this review indicated a potential prosurvival effect of PRP on the fat when suitable PRP concentrations were used. Clinically, the concentration that appears to obtain the most favorable results and that clinical efficacy can be expected with a four- to six fold increase with respect to baseline levels. Part of evaluation of satisfaction, is the volume entity; which is not only affected by the resorption rate, but also by the lipoaspirate itself which contains from 5% to 25% fluid content, also fluctuation due to present edema and fluctuation in patient BMI; all affect postoperative follow up assessment. ²² The main limitation of the previous lipofilling techniques was as crystal clear; the autograft reabsorption high rate; but still; even after enhancing with PRP, PRP did not eliminate that completely.

5. Conclusion and Recommendations

Oncoplastic surgery still leads to challenging assortment of breast deformities. The deformity may progressive and get amplified notoriously in time as a result of breast irradiation. Safety of fat grafting for breast cancer patients; not only for reconstruction, but for rejuvenation and for regeneration too, but ischemia and hypoxia are the main obstacles of lipofilling. Moreover, the degree of reabsorption of the injected adipose tissue is unpredictable. PRP has been emerging as innovative approach to enhance fat graft survival and maintenance. Our results concluded that PRP enhances the lipoinjectate subjectively, with lesser reabsorption rate and complications. We recommend further assessment of the results of PRP-enhancement on fat graft outcome; by further investigation on cellular level (count and quality) providing more objective findings. Also; we recommend to investigate the use of PRP enhanced technique on immediate breast reconstruction. We recommended the affiliation of a nutritionist to the medical panel to advice patients post operatively on a diet to avoid jeopardizing their weight/BMI variations whilst meeting their current nutritional needs.

Conflict of Interest

The authors declare no conflict of interest or financial ties to conclude.

References