Die aktuellen Leitlinien für Autologe Fettgewebstransplantationen der Deutschen Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) und der Fat Graft Task Force der American Society of Plastic Surgeons (ASPS) – ein transatlantischer Vergleich

Zusammenfassung

Problemstellung Die zunehmende Verwendung von autologen Fetttransplantationen veranlasste 2009 die American Society of Plastic Surgeons eine Fat Graft Task Force (AFGT) zu etablieren und in 2015 die Deutsche Gesellschaft der Plastischen, Rekonstruktiven und Ästhetischen Chirurgen (DGPRÄC) gemeinsam mit drei weiteren Fachgesellschaften (DDG, DGMKG, DGGG) an Hand der bislang publizierten Ergebnissen Behandlungsleitlinien zu erstellen. Die vorliegende Arbeit will die beiden Leitlinien hinsichtlich Ihres Anliegens, einer sicheren Durchführung von autologer Fetttransplantation, vergleichen.

Methoden Die AFGT stützt ihre Empfehlungen ausschließlich auf Parameter der evidenzbasierten Medizin. Die DGPRÄC bewertet unter Berücksichtigung der aktuellen Literatur im Rahmen eines vierstufigen Expertenkonsenses das Vorgehen nach allgemeinen Anforderungen der Operativen Medizin und gesetzlichen Vorgaben.

Ergebnisse Beide Gesellschaften stimmen in Indikation und technischen Vorgehen weitestgehend überein: Fetttransplantationen sind indiziert zum Brustaufbau, zur Rekonstruktion von Gewebsdefiziten oder Deformitäten. Beide weisen auf die Risikogruppe bestimmter Brusttumoren (BRCA-1, BRCA-2) bzw. familiäre Prädispositionen hin. In fast allen Anwendungsbereichen sind Ergebnisse abhängig von der verwendeten Applikationstechnik und den Erfahrungen eines Operateurs. Randomisierte, prospektive Studien für bestimmte Verfahren fehlen. Aufgrund der Einzelberichte und Expertenmeinungen liegt zwar nur eine Evidenz-Stufe von IV–V nach Einschätzung der AFGT vor. Demgegenüber vermittelt die DGPRÄC detailliertere Vorgehensverfahren und erreicht durch das Experten-Konsensusverfahren eine deutlich stärkere Aussagefähigkeit als die Leitlinie der AFGT.

Zusammenfassung Beide Expertengremien empfehlen die Durchführung autologer Fetttransplantationen bei entsprechenden Indikationen und weisen darauf hin, dass es keine Standardverfahren für ein bestimmtes Vorgehen gibt. Die publizierten Leitlinien sollen Hinweise geben auf die richtige Patientenselektion, eine optimale Technik, mögliche Komplikationen und realistische Erfolgsaussichten. Die DGPRÄC empfiehlt die Einhaltung der von ihr gegebenen praktischen Einzelrichtlinien einschließlich der gesetzlichen Vorgaben, um die Patientensicherheit zu gewährleisten und ist damit in der Praxis richtungsweisender und verbindlicher. Die AFGT rät dringend zur erweiterten Grundlagenforschung und zur Durchführung randomisierter, prospektiver Studien.

Abstract

Clinical Problem The renewed clinical interest in fat grafting for both reconstructive and aesthetic purposes prompted the American Society of Plastic Surgeons to establish a Fat Graft Task Force (AFGT) in 2009. Moreover, in 2015, the German Society of Plastic, Reconstructive and Aesthetic Surgeons (DGPRÄC), in cooperation with three relevant medical societies (DDG, DGMKG, DGGG), formulated statements on the provision of strategies for patient management and to guide physicians in clinical decision making, on the basis of the scientific literature, clinical experience and current laws. The aim of this paper is to compare both guidelines in regards to recommendations on fat grafting.

Methods Recommendations of the AFGT are based on evidence available in the published literature and graded within 5 (I–V) levels of appraisal. The available literature was reviewed by the aforementioned multidisciplinary consensus panel as well and graded according to a 4 level (I–IV) appraisal – focusing on general requirements for surgical procedures, quality of care, patient safety and legal provisions.

Results For indications and practical surgical procedures, the two societies reached a unanimous consensus: Fat grafting is indicated for breast reconstruction, reconstruction of tissue deficits, and deformations caused by prior operations. Both emphasize risk groups with breast cancer (BRCA-1, BRCA-2 and family predispositions). However, in any clinical setting, results depend on the surgical procedure applied and the individual surgeon’s experience. Since randomized, prospective studies are lacking and only individual case reports and clinical series or expert opinions have been published, the evidence grading does not exceed level IV to V. However, the DGPRÄC structured expert consensus panel conveys a more comprehensive and practical approach, and provides more reliable evidence to support their opinions.

Summary Both societies unanimously recommend fat grafting for appropriate indications and emphasize that there are no standard guidelines for any specific procedure. The published guidelines were developed to assist physicians in choosing optimal techniques, appropriate patient selection, and offer realistic advice on outcome and potential complications. The AFGT emphasizes the need for further research and randomized controlled studies. Overall, the DGPRÄC guidelines are more detailed, practically oriented and take into consideration current German and European Tissue Laws.

Schlüsselwörter

Leitlinien - Autologe Fettgewebstransplantation - Lipoinjektion - DGPRÄC - ASPS Fat Graft Task Force

Key words

guidelines - autologous fat transfer - lipoinjection - German Society of Plastic - Reconstructive and Aesthetic surgeons - ASPS Fat Graft Task Force

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