ADSC-enhanced versus conventional fat grafting for breast reconstruction: A systematic review and meta-analysis of safety and efficacy outcomes

Background: Adipose-derived stem cell (ADSC)–enhanced fat grafting may improve graft retention and aesthetic outcomes in breast reconstruction, but its safety and efficacy remain uncertain. This systematic review and meta-analysis compared ADSC-enhanced with conventional fat grafting using rigorous methodology and predefined subgroup analyses. Methods: Following PRISMA guidelines and PROSPERO registration (CRD42024553984), we searched six databases (January 2000–November 2024) for comparative studies. Random-effects meta-analyses assessed outcomes, with subgroups defined by ADSC preparation method, follow-up duration, and reconstruction indication. Results: Thirty-one studies (1,426 patients: 634 ADSC-enhanced, 792 conventional) met inclusion criteria. ADSC-enhanced grafting significantly improved fat retention (mean difference MD: 26.8%, 95% CI: 18.2–35.5; P <0.001; moderate-certainty evidence). Ex vivo–expanded ADSCs achieved the greatest improvement (MD: 64.6%, 95% CI: 60.5–68.7), while stromal vascular fraction methods provided moderate gains (MD: 17.0%, 95% CI: 8.6–25.4; P <0.001; I² =78%). Complication rates were similar between groups (18.4% vs. 17.2%; RR: 1.07, 95% CI: 0.65–1.77; P =0.78). Among 813 patients with prior breast cancer, recurrence rates did not differ significantly (5.3% vs. 3.4%; RR: 1.56, 95% CI: 0.10–24.3; P =0.75). Patient-reported and aesthetic outcomes generally favored ADSC-enhanced grafting. Conclusions: ADSC-enhanced fat grafting increases graft retention without raising complication or recurrence risk. Ex vivo–expanded ADSCs offer the greatest benefit, with stromal vascular fraction yielding moderate improvement. Standardized protocols and long-term safety data are needed to optimize clinical use.