Current German and American guidelines for autologous fat grafting - a transatlantic comparison

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. 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. 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. 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.