Breast Reconstructionand AugmentationUsing Pre -Expansionand AutologousFat Transplantation

Roger Khouri, MDa, Daniel DelVecchio, MDb,*

KEYWORDS� Breast reconstruction � Breast augmentation� Fat grafting � Fat transplantation

The concept of fat grafting for volume enhance- are all vitally important to the success of fat graft-

ment is not a new one. Although surgeons havebeen injecting fat for years,1,2 recent focus by clini-cians3 and basic science investigators has gener-ated a groundswell of enthusiasm for a ‘‘back tothe science’’ approach to fat transplantation.There is much to study to maximize both graftvolume and, more importantly, patient safety.This article outlines the authors’ approach tobreast deformities using fat grafting, withemphasis on current technique.

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FAT GRAFTING: HARVESTING

After Illouz’s4 seminal paper describing the abilityto remove fat cells from small port incisions usinga cannula, liposuction offered surgeons a low-morbidity new supply of autologous filler. Becausemany of the variables so important to fat graftingwere not well understood at that time, early resultswere disappointing as it related to volumemaintenance.

One of the most frustrating outcomes plasticsurgeons experience is often in fat grafting. Despitethe same surgeon, the same technique, and thesame recipient site, there is a wide variabilityamong volumes maintained over time (Fig. 1).

Donor age, donor site, harvesting technique andinstrumentation used with harvesting, processingtechnique, injection technique, and recipient sitemanagement both pregrafting and postgrafting

a Dermatology and Plastic Surgery, Key Biscayne, FL, USAb Back Bay Plastic Surgery, 38 Newbury Street, Boston, M* Corresponding author.E-mail address: dandelvecchio@aol.com (D. Del Vecchio).

Clin Plastic Surg 36 (2009) 269–280doi:10.1016/j.cps.2008.11.0090094-1298/08/$ – see front matter ª 2009 Published by E

ing and to maintenance of volume.5 Looking to thescience in the organ transplantation literature mayhelp standardize techniques in this area.

Intuitively, donor (and recipient) age is thoughtto be a factor in the success of fat grafting. Animalstudies in nude mice suggest this to be the case.6

Data from human fat over a range of donor ages in-jected subcutaneously into nude immunocompro-mised mice, suggested higher volume retention inrecipients with fat from younger donors. In prac-tice, autologous fat grafting does not afford theopportunity to control for this variable and thismay only serve as a prognosticator for patientspreoperatively.

Harvesting techniques vary greatly in liposuctionand certainly impact cell survival and graft take.Several studies have demonstrated that lesssuction results in more viable adipocytes.7 Gener-ally, handheld syringe methods are thought totraumatize adipocytes less and are recommendedto harvest fat. In addition, smaller-gauge syringesare recommended so as to avoid fat clumpingand to ease in reinjection.

Ostensibly, one might think that surgically re-sected fat, which is then diced with minimaltrauma, maintains cellular integrity better than suc-tioned fat by any method, and results in bettergraft take.8 Ongoing studies are being performedin this area to understand better the role of mini-mizing graft trauma9 and there is an opportunity

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Fig.1. Fat grafting. Current variables.

Khouri & Del Vecchio270

to validate this question and potentially to improveinstrumentation in this area.

Fig. 2. Manual centrifugation in closed IV collectionbag system.

FAT PROCESSING

There have been multiple reports of ‘‘percent grafttake’’ by volume.10 Because of lack of standardi-zation in grafting technique, clinicians mustconsider rethinking the results of many of thesestudies. Sixty milliliters of aspirated fat using thetumescent technique decants to a variable aliquotof fat and serum, including blood and crystalloid.Sixty milliliters of aspirate may decant to 30 to40 mL of fat. When this fat is then centrifuged orrolled on a Telfa pad, two techniques used toconcentrate fat further, the resultant fat mayreduce to 20 mL by volume. It is not surprisingthat when fat is grafted, even if all the fat survives,in many cases one has already committed to atbest a 30% to 40% volume take, because that isthe actual amount of fat that has been insertedby volume.

Although separation by simple decanting uses1g to separate higher-density blood and crystal-loid from adipocytes, a high-speed centrifugeuses much higher gravitational forces (3g–5g)and separates fat from crystalloid extremely well.These centrifuges also require transfer of fat intomultiple individual 5- or 10-mL syringes. It hasbeen demonstrated, however, that subjectingadipocytes to 3g to 5g of centrifugation results ina higher degree of cell death.11 A compromisebetween these two techniques that the authorsuse is manual centrifugation. Prototype devices,similar to the geared concept used in salad spin-ners, can subject larger volumes of adipocytes to1g to 2g forces to separate out unwanted crystal-loid better, without subjecting the fat to excessive

(3g–5g forces) trauma or excessive syringe manip-ulation (Fig. 2).

Subjecting adipocytes to air can potentiallydamage the cells and can decrease their survival.In addition, the time between harvesting and rein-jection increases duration of hypoxia and poten-tially has an effect on adipocyte survival. Suchconcerns support the argument that fat graftingin large volumes (unlike those performed for lipor nasolabial folds) might best be accomplishedwith a team approach. Ostensibly, it is recommen-ded that an assistant or several assistants processfat simultaneously while surgical liposuctionharvest is performed.

INJECTION TECHNIQUE

Injection technique also varies and probably playsa role in fat grafting survival. Bolus injections are tobe condemned because they defeat the purposeof oxygen diffusion and usually result in fat lique-faction, necrosis, and oil cysts. Dispersing the fatas evenly as possible into as many interstices aspossible in the recipient tissue theoretically givesthe donor cells the highest chance of maintainingan oxygen diffusion gradient over the critical 3 to5 days postgrafting.

There are currently several preferred techniquesof grafting fat into the breast. The authors’preferred technique, the ‘‘mapping’’ technique,involves the use of small (3-mL) syringes handheldand connected directly to a 16-gauge blunt nee-dle. Markings are made in the recipient areas(Fig. 3) to aid in a systematic injection. An exactamount of fat (1–2 mL) is then injected slowly onwithdrawal. The needle is then inserted intoanother adjacent tunnel and the process isrepeated. This technique is more deliberate andexact but does take more time. In addition, itrequires the operator to deploy the plunger andwithdraw the needle at the same time.

Fig. 3. Mapping technique of fat injection.

Breast Reconstruction and Augmentation 271

A second technique is the ‘‘reverse liposuction’’method. A 30-mL syringe containing prepared fatis connected to short intravenous extension tubingand is connected to an injection needle. An assis-tant depresses the plunger at a desired rate (asdirected by the surgeon) while the surgeonfocuses only on the motion and location of theneedle. In this manner, a large volume of fat canbe randomly dispersed into the recipient site ina shorter period of time. It is vitally important tokeep the needle under motion at all times and tokeep the injection speed low to avoid bolus injec-tions. When starting out with fat grafting to thebreast the mapping technique is generallyadvised. To date there are no data suggestingone technique is superior.

Because many reports suggest at best 30% fattake, one controversy in fat grafting has beenwhether or not to overcorrect. Overcorrectionhistorically seemed alluring because one mightreach a desired end point knowing a significantamount of adipocytes would not survive. It isbelieved, however, that the increased interstitialpressure created in most cases results in lack ofoxygen diffusion and cell death, potentially of allthe cells.

Indeed, some of the best clinical results in fatgrafting have been demonstrated by those whopromote small serial volume sessions of fat graft-ing. The evidence suggests that this approach issuccessful because it respects the interstitial pres-sure limitations of the recipient site and in doingso, promotes diffusion during the initial criticaldays postgrafting.

THE ROLE OF THE RECIPIENT SITE

Recipient site management has only recently beensuggested as a potential important variable in fat

grafting. From the general surgery trauma litera-ture and from hand and upper extremity trauma,the importance of compartment pressure andgrave consequences of interstitial pressure arewell understood. If it is possible to increase thevolume of the interstitial space before fat grafting,it is potentially feasible to inject a larger volume ofgraft into the recipient site before reaching highinterstitial pressures.

Experience with the vacuum-assisted closure asa means of wound management has proved thatmicroangiogenesis is a direct result of negativemechanical pressure.12 The extensive vacuum-as-sisted closure data on vascular in-growth coupledwith the MRI findings from BRAVA-expandedbreasts support the authors’ thesis that increasedmicrocirculation, combined with the larger intersti-tial space created by the expansion, may bothcontribute to the potential for increased fatvolumes and increased diffusion gradients.Although such postulates are currently beingconsidered for animal study, mechanical difficul-ties related to immobilization of vacuum domeson animal subjects remain a significant challenge(Fig. 4).

The BRAVA bra was initially developed in the1990s to generate a nonsurgical negative pressurebreast enhancement. The device generatesa negative pressure that creates an inflow of fluid,in this case interstitial fluid, and increased vascu-larity. The device was typically worn nightly undera low negative pressure, and over 4 to 6 weeksbreast enlargement of a cup size on average wasachieved. Once the device was discontinuedfrom use, however, breast size regressed to thepre-expansion baseline.

When used as a recipient site modulator beforefat grafting, pre-expansion is thought to generatea more supple skin envelope, especially in recon-struction cases and in cases of irradiated tissue.In addition, the increased interstitial space isbelieved to allow for a larger volume of fat to begrafted while still dispersing the cells withoxygen-rich recipient site tissue. Clinically, theauthors aim for a twofold to threefold increase involume before grafting (Fig. 5).

Postoperatively, skin grafts are immobilized topromote secure apposition of the donor cells tothe recipient wound bed. This promotes anadequate diffusion gradient and greater likelihoodthat angiogenesis occurs. Searing of the graft ormovement of any type in this initial 3 to 5 dayscan prove fatal for a skin graft. It is believed thatimmobilization of the transplanted adipocyte canbest be accomplished with mild external negativepressure. The authors are currently advocatinguse of the BRAVA bra for 5 to 7 days postgrafting.

Fig. 4. VAC data demonstrate increased circulatory flow with negative pressure (top left). (Data from KCI.) Thetheoretical effect of negative pressure on breast circulation (top right). MRI of breasts pre-expansion (bottomleft). Postexpansion using BRAVA (bottom right). Note the real increase in vessel caliber and numberpostexpansion.

Khouri & Del Vecchio272

Not only does the mild negative pressure serve toimmobilize the fat in its interstitial space, it alsomay help with angiogenesis as has been demon-strated with the vacuum-assisted closure. Lastly,the domes of the external expander BRAVA unithelp protect the newly grafted tissue from externalmovement and trauma.

Fig. 5. A threefold to fourfold volume expansion of the rec

IMPROVED INSTRUMENTATION

In 1980, when Illouz first described the liposuctiontechnique, 10-mm cannulae were described. Thirtyyears later, clinicians are now rapidly removing fatusing 12-gauge cannulae with multiple side ports,in a less traumatic manner (Fig. 6).

ipient site is possible and desirable before fat grafting.

Fig. 6. Commonly used 12-gauge cannula for fat harvesting.

Breast Reconstruction and Augmentation 273

CELL PRESERVATION TECHNIQUES FROMTRANSPLANTATION LITERATURE

In the solid organ transplantation, cell preservationis maximized by hypothermia and extracorporealperfusion during organ transfer using a variety ofsolutions. One such solution, University of Wiscon-sin Solution,13 is a highly concentrated potassiumsolution that reduces cellular metabolism in thesolid organ during its period of cellular hypoxiaand anoxia, and is thought to reduce cellular deathfollowing reperfusion in the recipient site. Thishighly concentrated potassium solution is notused in vivo, but is used to perfuse the solid organwhile in transit and in preparation for transplanta-tion. In general surgery shock and trauma, a varietyof solutions are known to improve reperfusion andimprove cell survival following resuscitation. Theserepresent just a few starting points for severalpotential strategies that are suitable for study forpossible adoption in maximizing techniques of fattransplantation. Current research is underway toidentify optimal solutions in this area.14

BREAST RECONSTRUCTION ANDAUGMENTATION:THE EMERGING ROLEOF THE RECIPIENT SITE AND FAT GRAFTINGThe State of Mastectomy Surgeryin the United States

Annually in the United States, there are approxi-mately 182,000 newly diagnosed cases of breastcancer that require some type of surgical proce-dure to treat breast cancer.15 These generallyrepresent some form of mastectomy or lumpec-tomy; however, there are approximately 57,000breast reconstructions performed a year in theUnited States.16 If one assumes that all thesereconstructions are performed for immediate (orin the same year of the mastectomy) reconstruc-tion, at best only 31% of patients are receivingsome form of breast reconstruction. This numberis probably lower because many of the reconstruc-tions are performed on cases diagnosed andsurgically treated in prior years. This also meansthat every decade, approximately 1.2 millionwomen are electing to do nothing about their post-surgical breast deformity. Why do such a highpercentage of breast cancer surgery patients electto do nothing following lumpectomy or mastec-tomy? One postulate is that the degree ofmorbidity of the reconstruction outweighs the

perceived aesthetic improvement over the existingdeformity.

In this orphaned population, a low-morbidityprocedure to reconstruct breast defects thatresults in significant aesthetic improvement repre-sents a large opportunity.

The State of Breast AugmentationSurgery in the United States

An adequate discussion of augmentation withbreast implants is beyond the context of thisarticle. It is interesting to consider, however, therisk-reward analysis similar to that outlined in thepatient after breast cancer surgery.

Reviewing available statistics, there wereapproximately 348,500 cosmetic breast augmen-tations performed in the United States in 2007. Inaddition, retail data from Consumer Reportssuggests that at least 34% of women in the UnitedStates own padded bras.17 Based on standardassumptions about the United States populationand the percent of women of adult age, for everywomen who undergoes a cosmetic breastenhancement, there are over 100 women who,for whatever reason, would like their breasts toappear larger in some way. The same rational fornonsurgery (padded bras) may also exist as itdoes for breast reconstruction. Besides financialissues, concerns over artificial implants, and otherpersonal concerns, a remaining variable is that thedegree of morbidity of the augmentation does notoutweigh the aesthetic improvement over the ex-isting aesthetic concern. As in the case of recon-struction, a low-morbidity procedure to augmentbreasts that results in significant improvementrepresents a large number of potential patients,much larger than the reconstruction population.

Patient Evaluation: Medical

The patient presenting for breast reconstruction oraugmentation with autologous fat grafting shouldbe evaluated for associated medical conditionsthat might otherwise exclude them from safelyundergoing a liposuction procedure. Acutely, theliposuction aspect of the intervention is probablyhigher in morbidity than that of the breast fat graft-ing. Smokers are generally not advised as candi-dates for breast reconstruction with fat graftingwith pre-expansion. Donor site fat is evaluatedfor the likely availability of fully processed fat.

Box1Examples of baseline volume considerations

Case A: Augmentation

Existing breasts, 250 mL size. Desired finalbreast volume, 500 mL. Plan: pre-expansion todesired volume, then graft. Percent expansion5 (500–250)/250 5 100%.

Case B: Reconstruction

Existing breast skin, subcutaneous fat 50 mLsize. Desired volume, 500 mL. Plan: pre-expan-

Khouri & Del Vecchio274

Irradiated patients have been successfully treatedusing BRAVA pre-expansion. In irradiated recon-structions, the skin envelope expands more slowlyand serial expansion and injection sessions arerequired. It is generally advised to begin breastreconstruction in nonirradiated mastectomypatients and first become familiar with these tech-niques before embarking on treating irradiateddefects. The assessment of the opposite breastis addressed with the same principles as for anybreast reconstruction.

sion to desired volume, then graft. Percentexpansion 5 (500–50)/50 5 900%.

The number of sessions for Case A may be one,whereas the number may be four to five forCase B.

Patient Evaluation: The Role of Compliance

Animal studies with negative pressure pre-expan-sion are challenging because of difficulties main-taining a device in animal subjects. The same canbe said for patients with regards to BRAVA pre-expansion. There is no substitute for sustainedmoderate to high negative pressure pre-expansionto maximize pre–fat grafting volume of the recipientsite. Indeed, the earliest versions of the negativepressure pumps were low-voltage battery-oper-ated devices that exerted a low negative pressure.These patients exhibited less dramatic pregraftingexpansion when compared with more powerfulpumps currently used. These pumps are similar innegative pressure and in terms of size and porta-bility as the vacuum-assisted closure pump, andhave demonstrated a dose response curve with re-gards to both pre-expansion volume and to overallfat volume results postgrafting.

Based on experience with the dose responsedata, the authors believe there is no substitutefor adequate pre-expansion. The degree andextent of pregrafting expansion is directly propor-tional to the amount of grafting possible to main-tain a physiologic interstitial pressure. Lastminute ‘‘cramming’’ on part of the patient hasbeen experienced and does not result in success-ful preparation. It is ultimately the responsibility ofthe surgeon adequately to select, educate, coach,and troubleshoot their patients to ensure adequateand optimal pre-expansion. Patients should spendas much time in-office the first time they use theirbras to ensure they are properly educated andmotivated to use the device.

BASELINE VOLUME CONSIDERATIONS

The more breast and subcutaneous tissue there isto begin with, the easier it is to volume expand withnegative pressure. In addition, the less scardamaged (nonirradiated) the tissue is, the easierit is to expand with negative pressure. Thefollowing cases serve as extreme examples(Box 1).

Preferred Techniques

BRAVA: recipient site preparationIn cases of mastectomy and for augmentation, theBRAVA dome is placed for 3 to 4 weeks and isworn 12 hours daily. For the last 4 to 5 days beforefat grafting, it is advised to wear the domes 24hours a day. Circumferential pressure at the edgesof the domes can create skin sensitivity and thisshould be explained to patients who shouldreduce the degree of negative pressure. Nonirradi-ated skin and subcutaneous tissue has greaterpotential for parenchymal expansion than casesperformed in irradiated tissue, which requiresmore serial sessions (Fig. 7).

The location and degree of body fat available isanalyzed to evaluate the existence of an adequateamount of donor fat. Because there are so manyvariables (amount of tumescence, degree ofbleeding, time allowed for tumescent solution toset) it is impossible to formulate a standard ratioof aspirate to actual processed fat by volume. Asa conservative rule, four to five times the desiredvolume of fat needed for grafting should be avail-able to be harvested as aspirate. For example, ifreconstruction using 400 mL of fat is planned,the patient should be able to render at least 1600to 2000 mL of aspirate to ensure adequate donormaterial.

Aspirate 5 5�Graft ; 2000 mL 5 5� 400 mL

Considering the pre-expansion effort the patientmust tolerate, it is always better to have more thanless fat available.

In the case of augmentation with 300 mL of faton each side, a minimum of 3000 mL of aspirateis recommended. Patients with body massindexes as low as 23 to 24 have been successfully

Fig.7. Augmentation (top), mastectomy (middle), irradiated mastectomy (bottom) sites with pre-expansion. After3 to 4 weeks, note the varying range of expansion possible in each category.

Breast Reconstruction and Augmentation 275

treated. The lower the body mass index, thegreater the number of donor sites (abdomen,knees, thighs, and so forth) that must be enteredto harvest adequate amounts of aspirate and fat.

Lipografting: preoperative planningOn the day of surgery patients are photographedand marked as usual for liposuction. Markingsare made for injection sites on the breasts andlines are made on the breast mound to ensureproper dispersion of the fat grafts. Patients are

brought into the operating room still wearing theBRAVA bra to maximize expansion closer to thepoint of injection. Once all the fat is harvestedand processed, the Bra is removed, the site isprepared and redraped, and injection takes place.

Harvesting and collectionFat is harvested using a 12-gauge blunt cannulawith multiple side ports. Syringe aspiration isused as opposed to high negative pressuremachine techniques. To avoid desiccation,

Khouri & Del Vecchio276

a closed system is used, transferring the fat fromthe syringe directly into an empty sterile intrave-nous bag by an extension tubing setup (Fig. 8).

ProcessingOnce an adequate amount of aspirate is har-vested, the collected intravenous bags are dec-anted of unwanted fluid and are placed intoa manual centrifuge. This manual centrifuge furtherseparates fluid from the adipocytes without sub-jecting the cells to excessive handling, desicca-tion, or trauma, as is postulated with high-speedcentrifugation in small syringes.

Once the fat is properly processed in thismanner, the fat is then drawn back into 3- or5-mL syringes from the intravenous collectionbags using a three-way stopcock, and graftingbegins.

Recipient site techniques: needle band releaseMultiple radial needle insertions are made aroundthe breast mound to disperse the grafted adipo-cytes maximally and to ensure as many differentplanes as possible. Before grafting the fat, if thereare breast shaping issues that need to be ad-dressed these can be performed at this time.

In many breasts, fibrous ligamentous tissue orbands distort the breast mound, such as in con-stricted inframammary folds or in the case oftubular breast deformities. Because expansion ofthe parenchymal space places these bands underhigh tension, it facilitates the transaction of thesebands using an 18-gauge needle, simply by insert-ing the needle in the area of the band and throughproprioception, ‘‘feeling’’ the blade of the needlecut the band. In this manner, it is possible to‘‘expand’’ or ‘‘release’’ these constrictions furtherinternally in a manner similar to the externalrelease of a burn scar contracture. The inframam-mary fold can be lowered in constricted inframam-mary folds, and the constricted bases of tubularbreasts can be widened in this manner. It is

Fig. 8. Closed system method of collection and fat replant

important not to overrelease these bands,because too large a dead space might ensue.This reduces the interstices of the tissue andreduces the surface-to-volume characteristics ofthe recipient site.

Injection techniqueBolus injections are to be condemned becausethey defeat the purpose of oxygen diffusion andusually result in fat liquefaction and necrosis.

The mapping technique previously describedinvolves the use of small (3-mL) syringes handheldand connected directly to a 16-gauge blunt nee-dle. Through the multiple radial needle insertionsaround the breast mound, the needle is advancedin the subcutaneous plane and an exact amount offat (1–2 mL) is then injected slowly on withdrawal.The needle is then inserted into another adjacenttunnel and the process is repeated.

Injection into the prepectoral fat and the subcu-taneous fat is performed in as many different depthplanes as the recipient tissue tolerates. In the caseof mastectomy, the first session of grafting allowsfewer planes of grafting and reasonable volumesduring the first session (150–250 mL) should beplanned. For subsequent sessions, there aremore potential planes, because a thicker intersti-tial space exists. Generally, the more parenchymaone has to begin with, the larger volumes of fat thatcan be grafted. For first session reconstructionafter mastectomy, 150 to 250 mL of fat can be ex-pected. For augmentation or in subsequent graft-ing sessions in reconstruction, 200 to 300 mLcan be planed. For irradiated cases, one shouldbe extremely careful not to overgraft and shouldexpect a minimum of four to five sessions.

In no cases (breast augmentation, treatinga lumpectomy defect, breast asymmetry, or anyother cases where any breast tissue remains) is itever recommended to inject fat directly into breasttissue.

ation.

Breast Reconstruction and Augmentation 277

POSTOPERATIVEMANAGEMENT

Patients are instructed to wear the BRAVA bra 5 to7 days postgrafting. This potentially helps withgraft immobilization, potentiates neovasculariza-tion, and definitely protects the breast fromexternal pressure or trauma.

REPRESENTATIVE RESULTSBreast Reconstruction

The patient in Fig. 9 had bilateral mastectomy(radical on the right) and had four serial sessionsof BRAVA pre-expansion and fat grafting sessionsof 150 mL each time.

Breast Reconstruction for Severe Asymmetry

The 20-year-old patient in Fig. 10 had a giantcongenital nevus excised as a child and demon-strated hypomastia on the left, documented

Fig. 9. Patient with bilateral mastectomy and BRAVA pre-e

by MRI. She underwent 3 weeks of BRAVApre-expansions to increase her parenchymalspace and to increase the vertical skin envelopedeficiency. She underwent a single session withgrafting of 300 mL into the left breast. Her postop-erative result at 6 months reveals retention ofgrafted fat volume.

Breast Augmentation: Postpartum Deflation

The 33-year-old patient shown in Fig. 11 desiredlarger breasts after having several children andexperiencing some mild deflation. Although shewore a padded bra and desired a cup sizeincrease in volume, she did not wish to have breastaugmentation with implants. She underwent3 weeks of BRAVA pre-expansions to increaseher parenchymal space bilaterally. She underwenta single session with grafting of 250 mL into

xpansion reconstruction; three sessions, 600 mL total.

Fig.10. (A) Patient with severe breast asymmetry and BRAVA pre-expansion reconstruction. (B) BRAVA pre-expan-sion increases parenchyma and skin envelope. (C) Six months after 280 mL of fat transplanted into the left breast.

Khouri & Del Vecchio278

Fig.11. The patient is shown pre-expansion (left) and 9 months after fat grafting (right).

Breast Reconstruction and Augmentation 279

each breast. At 9 months postgrafting, shedemonstrates adequate volume maintenance.

A COMPARISON OF BREAST RECONSTRUCTIONUSING THREE TECHNIQUES

Table 1 helps delineate some of the main differ-ences between currently popular reconstructionoptions and breast reconstruction using pre-expansion and autologous fat transplantation.

CONTROVERSIALTOPICS

At the time of this communication, it is early days inbreast augmentation and reconstruction using fattransplantation. There are more questions thanthere are answers, and it is easier to ask than toanswer the questions. The following representsome of the biggest controversies and challengesfacing this technique in the near, medium, andlong term.

Table1Differences among breast reconstruction options

Tissue Expander/Imp

Pain level Moderate

No. procedures 2

General anesthesia 2

Office visits forexpansion

3–5

Expansion type Serial, office based

Recipient site skin Thinned

Hospital days 0–1

Donor site morbidity NA

Patient compliance Patient passive

Reoperation tolerance Moderately possible

Cost to system Moderate

Imaging and Detection of Breast Cancer

In 1987, the American Society of Plastic Surgeonsposition paper strongly condemned fat grafting tothe breast suggesting fat grafting would distort theability of breast cancer detection. Breast fat graft-ing has been demonstrated to sometimes result inmicrocalcifications.18 Although many of thesecalcifications are believed to be distinguishablefrom calcifications of higher grade that aresuggestive of malignancy, unnecessary biopsieshave resulted from this effect.

Risk of Cancer: The Aromatase Question

It is well known that one in nine women experiencebreast cancer in their lifetime. Although it takesa nearly impossible study size to prove causalityor statistical significance, the question has beenraised that aromatase, a breakdown product ofadipocyte necrosis, might cause breast cancer.The validity of this is unknown.

lant TRAM BRAVA

High Low

1–2 1–4

1–2 0–1

None None

None Continuous

NA Thickened

3–5 None

High Liposuction, bonus

Passive Compliance is key

Unlikely Simple

High Low

Khouri & Del Vecchio280

What is known is that surgeons have performedthousands of procedures over the past 20 years inlarge numbers that cause fat cell necrosis. Despitethousands of TRAM flaps, with a high degree of fatnecrosis in zone II and III, breast liposuctions, andbreast reductions, there is no evidence, retrospec-tive or prospective, that these procedures areassociated with a higher degree of breast cancer.

Such facts should not be sufficient, however, asto ignore the question of safety. Although there arecurrently models being developed to evaluate thiscarcinogenic potential in an animal model, thereality is that the answer in humans will not beavailable before the widespread use of this tech-nique. Any patients entertaining any breast fatgrafting, including reconstruction patients andbreast augmentation patients, must be given fullinformed consent as to the unknown risks of thetechnique. Although many suggest this techniquenot be performed without the approval of aninternal review board, the reality is that the tech-nique is already being performed.

There is an unmet clinical need for more institu-tional review board–approved, multisite studiesthat can demonstrate reproducible and saferesults by many independent surgeons. Suchcollective data in the literature will eventually helpdelineate the safety issues as they relate to carci-nogenesis and cancer detection.

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