Efficacy and safety of fat grafting in breast reconstruction: A systematic review and meta-analyses of outcomes following mastectomy

Abstract

BACKGROUND: Autologous fat grafting (AFG) is increasingly used in postmastectomy breast reconstruction to enhance contour, improve tissue quality, and address radiation-induced fibrosis. However, uncertainty remains regarding long-term volume retention, complication risks, and patient-reported outcomes, particularly in oncologic populations. METHODS: This Preferred Reporting Items for Systematic Reviews and Meta-Analyses-compliant systematic review and meta-analysis (PROSPERO CRD420251132758) searched Medline, Embase, CENTRAL, and Scopus (2010-2025) for comparative studies evaluating complications or volume retention after AFG. Random-effects modeling assessed heterogeneity using I(2) and t(2). Sensitivity analyses excluded flap-augmented and water jet-assisted techniques. Enriched graft methods were synthesized narratively. RESULTS: Thirteen studies were included. Six nonenriched studies reported volume retention ranging from 26.0% to 74.8% at 3 to 12 months. The pooled mean retention was 47% [95% confidence interval (95% CI), 31.5-62.5; I(2)=99%]. Excluding flap-augmented and water jet studies yielded a lower pooled retention rate of 35.1% (95% CI, 25.9-44.3). Follow-up time did not significantly lead to moderate retention (p=0.97). Enriched grafting techniques demonstrated higher retention (78-89%) but were too heterogeneous for pooling. Seven studies contributed to complication analysis. AFG was associated with a numerically higher rate of fat necrosis [risk ratio (RR), 2.37; 95% CI, 0.80-7.01], although this did not reach statistical significance. No significant differences were observed in any complication category. Complication rates were comparable in irradiated cohorts. Patient-reported outcomes (primarily the Breast-Related Quality of life Questionnaire) consistently favored AFG. CONCLUSION: AFG is a safe adjunct in postmastectomy breast reconstruction, demonstrating moderate volume retention without increased postoperative morbidity. Patient satisfaction consistently improves with AFG. Standardized volumetric assessment and technique specific stratification are needed to optimize outcomes.