|Year : 2019 | Volume
| Issue : 4 | Page : 1297-1302
Assessment of autologous fat transfer to the breast: clinically and radiologically
Fouad M Ghareeb1, Mohammed G Ellabban2, Dalia M Elsakka1, Souzan F Omar3, Ahmed A Atia4
1 Department of Plastic and Reconstructive Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Radiology, Faculty of Medicine, Menoufia University, Menoufia, Egypt
3 Department of Plastic Surgery, Matria Teaching Hospital, Cairo, Egypt
4 Department of Plastic and Reconstructive Surgery, The Heart of England NHS Foundation Trust, Birmingham, England
|Date of Submission||28-Oct-2018|
|Date of Decision||25-Nov-2018|
|Date of Acceptance||02-Dec-2018|
|Date of Web Publication||31-Dec-2019|
Ahmed A Atia
Department of Plastic and Reconstructive Surgery, Matria Teaching Hospital, Cairo
Source of Support: None, Conflict of Interest: None
The aim was to assess the results of autologous fat graft to the breast through the rate of fat necrosis, cyst formation, and calcification patterns to avoid unnecessary breast biopsies.
Autologous fat transfer is widely used in plastic surgery for both reconstructive and esthetic purposes.
Patients and methods
This study included 30 patients, from September 2015 to February 2018. Baseline mammography was done for patients 40 years or older and ultrasound scans for those younger than 40 years and then repeated at 6 and 12 months postoperatively.
The age of the patients ranged 19–51 years. The mean amount of the fat transferred to each breast was 252.17 cm3 with range of 100–410 cm3. No major complications were recorded. Six months after breast lipofilling, six (25%) patients of 24 patients younger than 40 years showed multiple small anechoic and hypoechoic lesions (solid nodules) with disruption of surrounding normal breast tissue. Three patients showed cystic lesions of variable size. Microcalcifications were detected in four mammograms (66.6%) of the six patients older than 40 years. One year after breast lipofilling, cystic lesions increased to five. Microcalcifications were detected in three patients. The microcalcifications in the fourth patient had an increased amount of calcifications and progressed to macrocalcification.
Fat grafting to the breast can be associated with complications such as fat necrosis, liponecrotic cysts, and calcifications. The high incidence of these complications is associated with improper technique of fat grafting.
Keywords: autologous, breast, fat, mammogram, necrosis, ultrasound
|How to cite this article:|
Ghareeb FM, Ellabban MG, Elsakka DM, Omar SF, Atia AA. Assessment of autologous fat transfer to the breast: clinically and radiologically. Menoufia Med J 2019;32:1297-302
|How to cite this URL:|
Ghareeb FM, Ellabban MG, Elsakka DM, Omar SF, Atia AA. Assessment of autologous fat transfer to the breast: clinically and radiologically. Menoufia Med J [serial online] 2019 [cited 2020 Mar 29];32:1297-302. Available from: http://www.mmj.eg.net/text.asp?2019/32/4/1297/274259
| Introduction|| |
Autologous fat transfer was first performed by Neuber in 1893 to correct depressed scars on the face. The first report of autologous fat grafting for breast reconstruction was done on 1895, when Czerny transplanted a lipoma from the back to reconstruct a breast mound after a mastectomy defect. Peer in 1950 had an initial report of a fat graft survival rate of 50% at 1 year, which was challenged by Ellenbogen in the 1980s with an improved technique and outcome. This together with the advent of liposuction in the 1980s broadened the applications and practice of fat grafting .
In 1987, Bircoll was the surgeon who reported on autologous fat injection for breast augmentation using fat from liposuction . Despite the popularity of breast lipofilling for cosmetic and corrective indications in female breasts, the procedure has a long history surrounded by a great deal of controversy . In 1987, the American Society of Plastic Surgeons prohibited the use of autologous fat grafting to the female breasts because of concerns that it would interfere with subsequent cancer screening and that adipocytes may have tumor-promoting effects .
Fat grafting regained popularity in 2007 after confirmation by Coleman that fat tissue can be transplanted safely if meticulous care is exercised in the preparation and transfer of fat cell . The aim of this study was to identify the results of autologous fat graft (AFG) to the breast through the rate of fat necrosis, cyst formation, and calcification patterns to avoid unnecessary breast biopsies.
| Patients and Methods|| |
This prospective clinical study was conducted at Department of Plastic Surgery, Menoufia University hospitals, from September 2015 to February 2018. It was approved by the ethical committee on July 2016. It included 30 patients who visited the plastic surgery outpatient clinic asking for breast enhancement by autologous fat transfer with stable medical conditions with age range from 19 to 51 years old.
All the patients signed for informed consent for photography before and after surgical procedures including publication for research issues.
Patients excluded from this study were those with a history of breast cancer, having psychological instability with unrealistic expectations, and medically unfit. Baseline mammography was done for patients 40 years or older. Breast mammography was assessed for the presence of micro/macrocalcifications or abnormal masses. Ultrasound scans were done for those under 40 years old to assess the presence of any abnormal cystic lesions or abnormal lymph nodes. All patients were prospectively followed up at 6 months and 1 year after the procedure (by mammography and ultrasound according to their age) to detect signs of fat necrosis, development of microcalcifications, areas of architectural distortion, development of abnormal cysts, and evaluation of the cyst contents. Final assessment was performed 1 year after the last session of fat transfer.
Important landmarks of the breast included the midline, breast meridian, inframammary fold, and suprasternal notch – nipple line, besides marking the donor sites for liposuction. Twenty-six (86.7%) patients were performed under general anesthesia, and four (13.3%) patients were performed under local anesthesia for the first session of the breast lipofilling. Five (100%) patients were performed under local anesthesia for the second session of the breast lipofilling. During breast lipofilling, patients were placed in a supine position with elevation of the upper half of the table 30° and arms abducted 90°. The same plastic surgery team using the Coleman technique did the surgery.
The ideal donor site is patient dependent, based on patient preference and availability of fat at the donor site. The fat graft was harvested from the abdomen, flanks, back, inner thigh, and arms. Donor sites were infiltrated with 1 l normal saline, 1 ml epinephrine (1: 1000), and 30 ml 1% xylocaine ('super wet' technique). We waited for ∼20 min to allow for dispersion of the tumescent solution and for optimizing the effect of epinephrine to minimize the blood loss during liposuction. Fat was harvested using a 50-ml luer lock syringe attached to a 3-mm harvest cannula. The aspirated fat was centrifuged at 3000 rpm for 3 min. Centrifugation allows separation into three phases: the supernatant (containing lysed cells), the precipitate (blood residuals), and the intermediate phase (purified adipocytes).
The purified fat is injected in multiple layers and multiple directions, from deep to superficial areas and from retropectoral to subcutaneous tissues using a 20 G blunt cannula with 20-ml luer lock syringe. The access for fat injection was at the middle point of the inframammary crease or the axillary tail of the breast and at the margin of the areola. Closure of all wounds for liposuction and fat transfer was done using 5/0 prolene, and then the breast was softly massaged until the lump induced by the injection had disappeared. The patients were instructed to keep wearing the pressure garment for 4 weeks and received the postoperative medications (e.g., pain killers) and follow-up appointments.
All data were collected, tabulated, and statistically analyzed using SPSS 19.0 for windows (SPSS Inc., Chicago, Illinois, USA). Quantitative data were expressed as mean and SD. Qualitative data were expressed as number and percentage. Parametric tests such as t-test were used when data followed or being transformed to normal distribution. On-parametric tests such as χ2 were used when data did not follow normal distribution. P value was considered significant if less or equal to 0.05.
| Results|| |
The study included 30 patients asking for breast enhancement by autologous fat transfer. The age of the patients ranged from 19 and 51 years old, with mean age of 31.23 years. Twenty-four (80.0%) patients were younger than 40 years who underwent radiological assessment by breast ultrasound, and six (20.0%) patients were older than 40 years who underwent radiological assessment by breast mammogram. The mean BMI was 26.9, with range of 24–30 [Table 1].
|Table 1: Ag, BMI, amount of breast lipofilling, anesthesia, and radiological examination of patients included in the study|
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A total of 25 (83.3%) patients underwent one session of breast lipofilling, and five (16.6%) patients underwent a second session of further fat transfer to the breast after 6 months of the first session.
In this study, breast lipofilling was simultaneously done with other procedures in 21 (70%) patients, including liposuction for other areas more than the needed amount of fat for breast lipofilling in 11 (36.7%) patients, fat transfer to the buttock in nine (30.0%) patients, abdominoplasty in eight (26.7%) patients, scar revision for old breast reduction in one (3.3%) patient, vertical thigh lift in one (3.3%) patient, and arm lift in one (3.3%) patient. Liposuction areas for first session of breast lipofilling include flanks in 24 (80.0%) patients, abdomen in 19 (63.3%) patients, inner thigh in seven (23.3%) patients, and arms in five (16.7%) patients.
The mean volume of the injected fat during first session for right breast is 259.83 cm 3 ranging from 125 to 410 cm 3 and for left breast is 252.17 cm 3 ranging from 100 to 410 cm 3. During the second session, it was 120 cm 3 for right breast, ranging from 100 to 200 cm 3, and for left breast 98 cm 3, ranging from 90 to 100 cm 3.
The baseline radiological examination for all patients showed no radiographic abnormality. A total of 24 (80.0%) patients younger than 40 years underwent radiological assessment by breast ultrasound and six (20.0%) patients older than 40 years underwent radiological assessment by breast mammogram.
Six months after breast lipofilling
Breast ultrasound showed no radiographic abnormality in 18 (60.0%) patients, and multiple small anechoic and hypoechoic lesions (solid nodules) with disruption of surrounding normal breast tissue were found in six (25%) of the 24 patients younger than 40 years. The total number of solid nodules was 14, where five were anechoic and nine nodules were hypoechoic. The location of the nodules correlated with the area of the fat grafted. Three patients showed cystic lesions of variable size: two are simple and one is complicated by calcified wall.
Breast mammogramshowed no radiographic abnormality in two (33.4%) patients, and microcalcifications were detected in four (66.6%) patients of the six patients older than 40 years. These small (2 mm), round deposits were either isolated or associated with small, pale fat nodules. This type of calcification appeared to have typical benign features: thin-walled calcifications in oil cysts or coarse irregular calcifications. One patient showed clear, well-focused images of cystic lesions, most probably oil cyst.
One year after breast lipofilling
Breast ultrasound showed multiple small anechoic and hypoechoic lesions with disruption of surrounding normal breast tissue found in six (25%) patients. No newly formed lesions were found. Most of the detected nodules remained unchanged in shape and size after 1-year follow-up. Only in one patient, one nodule dissolved to cystic lesion. [Figure 1] Cystic lesions were observed in five patients, this means resorption of some nodules in two patients as they were three only after 6 months.
|Figure 1: Breast cyst with partially dissolved fat inside 12 months postoperatively.|
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Breast mammogram showed no radiographic abnormality in two (33.4%) patients, and microcalcifications were detected in three patients. Macrocalcification was founded in one patient, which means the microcalcifications in the fourth patient had an increased amount of calcification and progressed to macrocalcification. One cystic lesion was detected [Table 2] and [Figure 2], [Figure 3], [Figure 4], [Figure 5].
|Table 2: Radiological finding after 6 months and 1 year of breast lipofilling|
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|Figure 2: A 26-year-old patient underwent liposuction of abdomen, flanks, and back with fat transfer to the buttock and two sessions of breast lipofilling. First 220 cm3 of fat was injected for each breast and second 100 cm3 fat for upper pole. (a) Baseline, (b) 6 months postoperatively, and (c) 12 months postoperatively.|
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|Figure 3: Breast ultrasound for the patient (Fig. 2): (a) baseline; (b) breast nodule at 6 months postoperatively; and (c) breast nodule increased in size at 12 months postoperatively.|
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|Figure 4: A 41-year-old patient underwent liposuction of abdomen, flanks, and arm with one sessions of breast lipofilling, and 350 cm3 fat was injected for each breast. Breast mammogram at (a) baseline, (b) 6 months postoperatively, and (c) 12 months postoperatively.|
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|Figure 5: Breast mammogram for the patient (Fig. 4): (a) baseline, (b) microcalcifications with structural abnormality at 6 months postoperatively, and (c) microcalcifications, with more with structural abnormality 12-month postoperative.|
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No immediate serious complications occurred in any patients during or after fat grafting procedures, such as hematoma, infection, cellulitis, or thromboembolism. The main complications were breast pain in four (13.3%) patients, fat necrosis with yellowish discharge in one (3.3%) patient, irregularities of the donor sites of liposuction in three (10.0%) patients, fluid collection of the donor sites of liposuction in two (6.7%) patients, asymmetry of both breast sizes in one (3.3%) patient, and palpable mass in one (3.3%) patient by breast ultrasound diagnosed as liponecrotic cyst and drained through needle aspiration in the outpatient clinic with systemic oral antibiotic therapy, with no need of hospitalization.
Every patient (at 6 months and 1 year postoperatively) was asked to answer a patient satisfaction questionnaire and to give a score from 1 (dissatisfied) to 4 (highly satisfied) regarding each item of the following: the new breast size, breast shape, breast symmetry, esthetic results, and overall satisfaction. This revealed high satisfaction in nine (30.0%) patients, satisfaction in 11 (36.7%) patients, neutral in seven (23.3%) patients, and dissatisfaction in three (10.0%) patients.
There was a close correlation in the percentage of the patient satisfaction as compared with the radiological finding. Overall, 77.8% of the patients were highly satisfied, observed in radiologically negative patients; 63.6% were satisfied, observed in radiologically negative patients; 71.4% were neutral, observed in radiologically negative patients; and 33.3% were dissatisfied, observed in radiologically negative patients.
| Discussion|| |
Graft survival percentage varies with the methods used to aspirate, prepare, and transplant the fat. It also varies with respect to the destination of the graft, with fat grafted into well-vascularized muscle surviving at a higher rate than fat grafted into a relatively oxygen-poor environment such as scarring tissue from previous breast surgery .
The technique of lipofilling must maximize survival of the fatty tissue, not only by minimizing trauma during harvesting and refinement but also by placing the living fatty tissue in small aliquots rather than large clumps. The less the grafted amount of fat with each passes of the cannula, the higher the percentage of the surface area of contact between the grafted fat and the recipient tissue. Fat necrosis and calcification can be avoided by increasing the fat survival rate by the proximity of the transferred fat to blood supply areas at the recipient site. If fat is transferred in large volumes, some of the fat cells may be too far from a blood supply. This can lead to fat necrosis. Therefore, transplanting fat in large clumps should be avoided .
Multiple studies report negative correlation between fat graft particle width and retention percentage after lipofilling. Long-term fat graft retention requires small volumes of fat to be diffusely distributed into a well-vascularized recipient site through well-separated tunnels. Fat graft survival is also largely dependent on the vasculature's ability to delivery oxygen blood through the capillaries surrounding the graft .
Few studies have addressed the issue of the rate of AFG absorption and the factors that may be associated with a higher or lower graft survival volume in the literature. Moreover, the mechanism of fat tissue survival and absorption is not fully understood. It is believed that fat tissue survives by nutrient diffusion from the serum within the first 48 h and then starts to regenerate .
It was thought that fat grafting to the breast could potentially interfere with breast cancer detection; however, no conclusive evidence of such interference has been found. Two cases of breast cancer after fat grafting to the breast were reported, but there was no delay in detection or treatment in these cases .
Cysts and calcification patterns in the subcutaneous and subglandular tissues where the fat grafts are injected can be differentiated from benign or malignant lesions. The features of fat necrosis, oil cysts, and calcification were identified by the presence of decreased signal intensity in the center of fat necrosis, which is the key to differentiation of fat necrosis from solid tumor. The cancerous tumor should not contain fat in the center of the lesion. Signal intensity of fat necrosis decreased on fat-suppressed images in contrast to the intensified signal of the mammary tissue or other breast lumps. Calcifications appear to be a low-intensity circle of the signal around a liponecrotic cyst .
In this study, breast lipofilling was simultaneously done with other procedures in 40% (12) of cases. Grant et al.  found that combination of cosmetic surgical procedures did not increase morbidity, and the potential benefits of combined procedures (a single recovery period, reduced surgery costs, and faster patient gratification) may be considered.
The number and size of nodules following fat transfer to the breast increases as the injection volume increases. As reported, the survival rate of the grafted fat is dependent on the total volume of fat used and the vascularity of the recipient site. We predicted that small amount of fat injected each time might improve the result .
There is an inverse relationship between the volume of fat that can be injected in a single session and the percentage fat graft survival (i.e., the more fat grafted, the lower its survival rate). Most of the clinical studies have addressed the issue of the rate of AFG absorption and the factors that may be associated with a higher or lower graft survival volume through manipulating the harvesting techniques, fat manipulation, stem cells, and related approaches .
Kim et al.  demonstrated in their study that the complications including fat necrosis and cyst formation occurred in 18 of the 102 patients (17.6%). The presence of a complication was associated with the volume of fat injected. The mean total volume of fat injected into the breasts was 67.5 cm 3 for those patients who developed complications, whereas the fat volume was 45.2 cm 3 for those without complications. Of the 18 patients with complications, 10 had fat necrosis, and eight had cystic lesions. Among them, only three patients complained of a palpable mass, and pathologic examination confirmed as fat necrosis. All cases complained of palpable mass that was conservatively managed, with no other procedure like surgical excision or drainage required, but regular follow-up was done.
Groen et al.  in a review of 33 studies reported 461 complications in a total of 5502 patients. The reported total complication rate was 8.4%, including nodules/masses 11.5%, cyst formation 6.9%, hematoma 6.3%, calcifications 5.2%, fat/liponecrosis 4%, granulomas 3.6%, infections/cellulitis 0.8%, seroma 0.8%, donor site infections 0.7%, abscess 0.6%, pneumothorax 0.2%, and delayed wound healing 0.1%.
In our study, the patient satisfaction and presence of a complication were associated with the volume of fat injected. The mean total volume of fat injected into the breasts was 322 cm 3 for those patients who developed complications following the procedure, whereas the fat volume was 223 cm 3 for those without complications.
| Conclusion|| |
The clinical outcome of breast lipofilling is dependent on the technique; according to the published literature, there no clear guidance to the optimal technique at each stages of fat grafting. The using of low suction pressure during liposuction, using of large bore-sized harvesting cannulas, applying of low centrifugation forces, decreasing the shear stress during injection, injection of small amount of fat, and optimizing the amount of fat injected to the capacity of the recipient breast were noted to improve the grafted fat survival rate. The chances of survival are higher among patients where the fat graft is less manipulated and more quickly reinjected. The less the grafted amount of fat with each passes of the cannula, the higher the percentage of the surface area of contact between the grafted fat and the recipient tissue and less the complication rate. The higher the survival rate of the fat grafts, the less the complication rate following breast lipofilling. Fat grafting to the breast can be associated with complications such as infection, liponecrotic cysts, fat necrosis, and calcifications. Such calcifications produce distinct radiologic features that may be differentiated from breast cancer, and no reports suggest an increased risk of malignancy associated with fat grafting. Finally, it is still very difficult to predict the percentage of the fat graft survival.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]
[Table 1], [Table 2]