Interest in the use of lipoinfiltration (fat grafting) to improve breast contour, size and symmetry deficiencies is increasing. Fat grafting is being used in the post-mastectomy patient, after breast conserving surgery and for primary augmentation. Despite promising results, this procedure has sparked an important debate on patient safety. Reduction mammoplasty, liposuction, implant augmentation, total and partial mastectomy and radiation all have the potential to cause physical exam and radiographic alterations in the appearance of the breast.
STRIVING FOR 'IDEAL' Autologous fat has the potential to be the ideal filler: it is nontoxic, readily available and feels natural. However, its current downfall is the inability to produce consistent and reproducible results. Further, a certain proportion will undergo necrosis, and the liponecrotic pseudocysts left behind can mimic the diagnosis of cancer recurrence by causing physical exam abnormalities and calcifications on mammogram. Clinical studies have reported rates of absorption from 25 to 90 percent, and animal studies based on more objective data have documented resorption rates of 60 to 70 percent.2 These complications make lipoinfiltration for primary augmentation controversial. At Georgetown University Hospital, we are initiating a 30-patient prospective study of autologous fat transplantation for breast augmentation. Pre- and post-procedure, each patient will undergo physical examination, photography and mammography; select patients will undergo breast MRI. All will be followed for five years to evaluate fat graft survival, physical exam abnormalities and radiographic changes. When selecting patients for and helping patients choose this elective procedure, it's important to balance the goals of the three main parties involved: the oncologic surgeon, the plastic surgeon and, most importantly, the patient. The oncologic surgeon cannot sacrifice close cancer surveillance for cosmesis, but it should be kept in mind during surgical planning, just as the plastic surgeon should think twice about using fat to augment an area that may eventually complicate screening and surveillance. It is also important to realize that patient goals may vary from those of both surgeons: not all patients elect to have reconstruction. Although frequent trips to the OR may improve aesthetic results, it should not be at the expense of a patient's mental and physical well being. A paradox exists: breast surgeons make every effort to limit the number of times a patient must go to the OR, while plastic surgeons plan staged procedures requiring multiple operations. DATA DESIRED Autologous fat grafting is an appealing option as an adjunct for breast reconstruction and primary augmentation. We recommend that patients have age-appropriate baseline mammograms before cosmetic breast procedures and specific locations of fat injections in the breast be documented. Age-appropriate breast cancer screening protocols should also be stressed. Many ongoing studies are investigating both clinical and molecular approaches to increase fat graft viability. Perhaps with their success, clinicians can decrease radiographic changes by improving graft survival. Studies with long-term follow up that include radiographic appearance, physical exam and cosmesis are needed to assure oncologic surgeons that fat grafting does not compromise cancer detection and/or treatment.References 1Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the reconstructed breast. Plast Reconstr Surg. 2005;116:1300-1305. 2Kaufman MR, Bradley JP, Dickinson B, et al. Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and long-term results. Plast Reconstr Surg. 2007;119:323-331. |
