Various fat grafting techniques for breast surgery have been proposed, but some have their critics.
One viable alternative to standard liposuction is tissue liquefaction technology (TLT), as embodied in the HydraSolve Lipoplasty System (Andrew Technologies LLC; Irvine, Calif.).
"By removing the fat with HydraSolve, the operating surgeon may be able to minimize the intermediate step of processing the fat for reinjection by effectively washing and separating the fat cells at the time of harvest,” says Terence M. Myckatyn, M.D., a professor of plastic and reconstruction surgery at Washington University School of Medicine in St. Louis, Mo.
Unlike competing technologies that rely on heat or a water jet to process fat, HydraSolve synergizes water with heat to efficaciously separate the fat cells with minimal trauma, according to Dr. Myckatyn.
After processing, “the fat is very clean, in tiny parcels, and ready for reinjection,” Dr. Myckatyn tells Cosmetic Surgery Times. “The actual clumps of fat are smaller than with other forms of liposuction and fat grafting. This translates into a smoother, easier reinjection back into the patient.”
In 2012, HydraSolve became the first FDA-approved liposuction device for fat grafting.
Dr. Myckatyn is co-author of a retrospective chart review in Aesthetic Plastic Surgery that involved 136 consecutive breast reconstruction patients, nearly all for either cancer or prophylaxis for cancer prevention, who underwent fat harvest with HydraSolve, for a total of 237 procedures (mostly bilateral).
The abdomen was the donor site for 50% of the cases, with the remaining two sites being the flanks and the thighs.
The overall complication rate for the study was 29%, with roughly 75% of adverse events due to fat necrosis at the recipient site.
“I believe our results are on par with standard liposuction,” says Dr. Myckatyn, whose practice group since 2014 has used HydraSolve on about 350 patients, the vast majority for breast reconstruction.
Beyond Breast Reconstruction
Beyond breast reconstruction, Dr. Myckatyn and his colleagues have started using HydraSolve for cosmetic breast augmentation and buttock augmentation.
Kamran Khoobehi, M.D., FACS, director of aesthetic training at Louisiana State University Health Science Center in New Orleans, said that the field of fat grafting is rapidly expanding from a minor procedure, with the fastest growing area being the Brazilian butt lift.
“The main concern for most plastic surgeons is the predictability of fat grafting results,” Dr. Khoobehi tells Cosmetic Surgery Times. “There are many techniques to harvest, process and inject fat; and most surgeons are looking for a more standardized process to achieve consistent results.”
Dr. Khoobehi has been advocating low negative pressure for harvesting, minimal manipulation for processing, and a meticulous small-volume grafting technique.
“There are many patients that had implant breast augmentation when they were younger,” said Dr. Khoobehi, who participated in a panel discussion on the controversies of fat grafting in breast surgery at the September annual meeting of the American Society of Plastic Surgeons (ASPS) in Los Angeles. “Now, after having kids, they want to remove their implants but are worried about the shape of their breast postimplant removal. Fat grafting provides an alternative to patients that no longer desire implants.”
Dr. Khoobehi has had the most success in using fat rather than implants for mastopexy to achieve more cleavage and upper pole fullness.
“There are patients that are not good candidates for implants or fat grafting alone,” Dr. Khoobehi said. “A combination of implants and fat grafting provides patients with the best possible outcomes for size, shape and feel.”
Dr. Khoobehi does not believe there will ever be one standardized process for fat grafting, “just as we do not have a standardized facelift or mastopexy technique.”
In the future, Dr. Khoobehi predicts there will be medications to enhance fat grafting, tools to make grafting and the process more streamlined, and possible laboratories to grow fat cell lines for transfer.
Fat Transfer Technique Tips
Injecting fat into the breast in tiny aliquots as opposed to squirting in a rapid fashion is the method advocated by Sydney R. Coleman, M.D., an assistant clinical professor of plastic surgery at New York University Langone Medical Center and the University of Pittsburgh Medical Center. “By squirting, there is a good chance you will end up with fat necrosis,” he says.
Dr. Coleman acknowledges there is a movement to speed up the surgery and complete it in less than 2 hours by squirting the fat transfer. “It takes much longer to meticulously place the fat, but it will save people a huge problem,” he says.
Using tiny aliquots is also more efficacious. “It allows you to shape the breast rather than simply enlarge it,” Dr. Coleman tells Cosmetic Surgery Times. “You can expand or sculpt a selected portion of the breast for different types of deformities such as lumpectomy or tuberous breasts.”
Dr. Coleman, a pioneer in fat transfer, who also participated in the controversies panel, says a second bone of contention is whether breast cancer detection is compromised by fat grafting. “The studies indicate that detection is actually improved by fat grafting because it makes the fat less radiopaque compared to breast implants or surgery which can obscure cancers,” he says.
Using sharp needles to inject fat is another red flag. Accidental intravenous injection of fat can cause intra-arterial infections, “especially if you are injecting large amounts of fat at once,” Dr. Coleman says.
Accidental intravenous injection of fat is already happening at an alarming rate in the buttock, according to Dr. Coleman. “But we have yet to figure it out completely,” he says.
Despite these uncertainties, Dr. Coleman believes that fat grafting to the breast is “an unprecedented tool for shaping and reforming the breast. However, it does pose potential problems with creating oil cysts and fat necrosis.”