Impact of Donor Site on Fat Graft Survival in Autologous Fat Transfer to the Breast: A systematic review

Background Autologous fat transfer has gained recognition as total breast reconstruction. Application remains constrained by unpredictable fat graft survival. Donor site selection may influence fat survival, but evidence remains inconsistent and consensus is lacking. This systematic review evaluated the impact of donor site selection on fat graft survival following autologous fat transfer to the breast. Methods MEDLINE, Cochrane Library, Embase, and Scopus were searched up to October 27, 2025. Eligible studies included randomized controlled trials and cohort studies reporting donor site and graft survival. Risk of bias was assessed using ROBINS-I V2. Meta-analyses were conducted using a random-effects model. Results Seven studies comprising 291 patients were included. Fat was harvested from the abdomen (n=211) or thighs (n=80). No study specifically addressed total breast reconstruction. Pooled mean graft survival was 56.04% (95% CI, 41.57-70.51; I 2 = 99.8%) at 12 months postoperatively for the abdomen and 34.13% (95% CI, 30.51-37.76; I 2 = 15.2%) at 6 months postoperatively for the thighs. All studies had a serious or critical risk of bias. Discussion Although fat graft survival in autologous fat transfer to the breast appears higher when fat is harvested from the abdomen compared to the thighs, these findings should be interpreted with caution. Due to low-quality evidence, time bias and substantial study heterogeneity, no donor site can be recommended based on fat graft survival alone. High-quality, standardized research is needed to clarify the role of donor site in graft survival as such evidence could guide surgical decision-making and improve outcomes in total breast reconstruction.