Background: Breast reconstruction is rapidly evolving, because of the changing face of cancer surgery and the growing acceptance of acellular dermal matrices and synthetic meshes. Although some early reports showed encouraging results after prepectoral breast reconstruction, there is a paucity of data on long-term outcomes. Methods: Between January of 2012 and March of 2015, 179 patients undergoing mastectomy were enrolled at the authors’ institution. Patients underwent mastectomy and immediate prepectoral breast reconstruction with the definitive implant entirely wrapped in a titanium-coated polypropylene mesh (TiLoop). The BREAST-Q questionnaire was administered before surgery and after 2 years. Capsular contracture was evaluated using the Baker scale. Oncologic, surgical, and aesthetic outcomes and changes in BREAST-Q score were analyzed over time. Results: Average follow-up was 38.5 months. A total of 250 mastectomies were performed. The locoregional recurrence rate was 2.1 percent. Complications requiring reoperation were recorded in six patients (2.4 percent) and implant removal was necessary in three cases (1.2 percent), followed by reconstruction with submuscular expanders. Grade IV capsular contracture was detected in five breasts (2 percent), whereas 212 breasts were evaluated as grade I (84.8 percent), 28 breasts as grade II (11.2 percent), and five breasts as grade III (2 percent). Patients reported significant high rates in the BREAST-Q overall Satisfaction with Outcome (73.8), overall Satisfaction with Breasts (72.5), Psychosocial Well-being (77.7), and Sexual Well-being (57.9), scoring a significant increase in these domains from the preoperative period to the postoperative period (p < 0.05). Conclusion: The authors report encouraging results of a prepectoral direct-to-implant reconstruction technique using a synthetic mesh, supporting the evaluation of the muscle-sparing subcutaneous approach as a valid alternative to traditional submuscular reconstruction. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Introduction: Cell-based therapies exploit the heterogeneous and self-sufficient biological environment of stem cells to restore, maintain and improve tissue functions. Adipose-derived stem cells (ASCs) are, to this aim, promising cell types thanks to advantageous isolation procedures, growth kinetics, plasticity and trophic properties. Specifically, bone regeneration represents a suitable, though often challenging, target setting to test and apply ASC-based therapeutic strategies. Areas covered: ASCs are extremely plastic and secrete bioactive peptides that mediate paracrine functions, mediating their trophic actions in vivo. Numerous preclinical studies demonstrated that ASCs improve bone healing. Clinical trials are ongoing to validate the clinical feasibility of these approaches. This review is intended to define the state-of-the-art on ASCs, encompassing the biological features that make them suitable for bone regenerative strategies, and to provide an update on existing preclinical and clinical applications. Expert opinion: ASCs offer numerous advantages over other stem cells in terms of feasibility of clinical translation. Data obtained from in vivo experimentation are encouraging, and clinical trials are ongoing. More robust validations are thus expected to be achieved during the next few years, and will likely pave the way to optimized patient-tailored treatments for bone regeneration.