Reply: Evidence-Based Scar Management

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We would like to thank Dr. Caviggioli and colleagues for their letter regarding our recently published study, “Evidence-Based Scar Management: How to Improve Results with Technique and Technology.”1 Dr. Caviggioli and colleagues have extensive experience with the use of autologous fat to improve scarring. They have been able to demonstrate improvement in scar suppleness with fat grafting, using objective measures with a durometer, and subjective measures with the Patient and Observer Scar Assessment scale.2 In addition, by showing the superiority of fat grafting compared to control saline injection, they were able to demonstrate that the improvement in scar quality was not simply the result of scar subcision, but that the grafted adipose tissue played a critical role in improving the scar. Other studies have demonstrated similar outcomes.3,4
The use of fat grafting is perhaps most useful in the treatment of stiff and damaged irradiated tissue. In addition to the study by Maione et al. demonstrating improved tissue quality and pain after fat grafting to the irradiated breast,5 a recent study suggested that autologous fat grafting in conjunction with implant-based breast reconstruction may lower the complication rate in irradiated breasts to a rate comparable to nonirradiated breasts.6 In animal studies, fat grafting of irradiated tissues has been shown to decrease fibrosis and improve vascularity.7
Despite the proven efficacy of fat grafting in the treatment of scarring, the safety of fat grafting to oncologic sites remains a topic of contention, given concerns that mesenchymal stem cells in the graft may potentiate the progression of existing tumors.8–10 However, in a recent large, multicenter study of postmastectomy reconstruction patients, fat grafting was not found to increase the risk of breast cancer recurrence.11 Similarly, fat grafting has been found to be safe in head and neck cancer reconstruction.12 In contrast, although fat grafts have not been shown to stimulate dormant breast cancer cells, they have been found to stimulate active breast cancer cells.13 Clearly, more large studies are needed to fully establish the safety of fat grafting in postoncologic reconstruction sites.
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