Behind The Medical Headlines

Lipofilling: a role in breast reconstruction surgery?

• Mr J Scott, Consultant Plastic and Reconstructive Surgeon, Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, Glasgow, UK

Summary

The potential for transplanting fat cells from one part of the body to another to correct contour irregularities, such as those caused by trauma or surgery, was recognised more than 100 years ago. However, this process remains experimental. In this article Mr John Scott provides an overview of recent surgical developments that may offer an alternative form of breast reconstruction following surgery for breast cancer.

Declaration of interests: No conflict of interests declared

Introduction

The potential for transplanting or grafting fat from one part of the body to another to correct contour irregularities was recognised more than 100 years ago. However, the survival of the transplanted fat cells requires a new blood supply to be established at the recipient site. Failure to achieve this leads to necrosis of the fat, with possible cyst formation, calcification, scarring and volume loss.

Until recently, therefore, with the unpredictable nature of the outcome, the technique of fat grafting or lipofilling has failed to achieve universal popularity. But significant interest in lipofilling has been rekindled by advancements in the technique developed by Dr Sydney Coleman, a plastic surgeon from New York.

The technique

The ‘Coleman technique’ involves the use of a syringe and cannula to aspirate fat from areas of relative adipose excess, commonly in the lower trunk and thighs. The aspirated fat is then centrifuged to separate the fat cells from residual blood, oil and other fluids.

The harvested fat cells are placed into small-volume syringes to facilitate the injection of tiny aliquots of fat into the recipient site. The injections are performed through specifically designed cannulae enabling narrow beads of fat cells to be placed in the recipient area.

When performing more than a single injection, the cannula is passed in multiple directions and depths to build up a 3-D latticework of injected fat. Theoretically, this enables each injected fat cell to be in close proximity to vascular recipient tissue, facilitating the creation of a new blood supply to the grafted fat. Failure to observe this technique can lead to the creation of injected ‘fat lakes’, which distance the injected fat cells from the surrounding vascular recipient tissue. Consequently, the risk of fat necrosis is increased along with the sequelae of cyst formation, calcification, scarring and contour irregularity.

The injection must be performed gently to prevent damage to the fat cells. Intravascular injection may produce a fat embolism, while acute visual loss and cerebral infarction have been reported after autologous fat injection to the face.

The quantity of fat injected is limited by the donor site availability and the volume of the recipient site. Thus, significant corrections often require more than one procedure. It is generally accepted that an initial overcorrection of the contour deformity of approximately 20% is required to allow for some fat resorption.

Indications

Soft tissue contour deformities may be secondary to developmental abnormalities, trauma, surgery or ageing. Recently, significant interest has developed in the role of fat grafting in the correction of breast shape abnormalities and aesthetic enhancement.

The first fat graft to the breast was performed in 1895. However, the contemporary attitude to ‘lipomodelling’ the breast has been cautious. The reason for this relates to concerns that the scarring and calcification associated with failed fat grafts may obscure the early detection of breast cancer by mammography. Interestingly, similar concerns have not diminished the popularity of breast reduction surgery and breast augmentation with implants, despite the associated risk of calcifications and potential imaging difficulties.

To answer the very valid safety concerns, both Coleman and Delay have published long term follow-up studies of their experience of fat grafting to the breast.

Coleman et al.¹ reviewed 15 patients with mammography after fat grafting to the breasts with a follow-up of 56 months. Mammography illustrated eight normal mammograms, four benign calcifications, one fat necrosis and two breast cancers.

Delay et al.² reported the ultrasound, mammography and magnetic resonance imaging (MRI) evaluation of autologous latissimus dorsi breast reconstruction secondarily augmented with fat grafts. The conclusion was that fat grafting does not affect the follow-up of patients with breast cancer.

These results, however, reflect the cautious and considered approach of two leading figures in the field of fat grafting to the breast. The published follow-up data represents a relatively small patient number. It is important to stress, therefore, that failure to apply such a methodical approach may potentially have disastrous consequences. The use of fat grafting for the aesthetic enhancement of a morphologically normal breast remains controversial and is not supported by the American Society of Plastic Surgeons.

Recently, Rigotti et al.³ reported a further fascinating application of fat grafting in the treatment of radiotherapy-induced tissue damage. The hypothesis is that adipose tissue is a rich reservoir of multipotent mesenchymal stem cells, which can secrete proangiogenic growth factors. Injection of lipoaspirate containing these stem cells may stimulate neovascularisation of the chronically ischaemic irradiated tissue. Thus, the ulceration and fibrosis associated with radiotherapy may be ameliorated. Impressive clinical pictures are presented to support this hypothesis.

Summary

The development of a more predictable technique for autologous lipofilling provides a potentially valuable addition to the armamentarium of the reconstructive surgeon. Cautious enthusiasm may see its application transform the current management of breast deformity and radiotherapy-induced soft tissue changes.

References

1. Coleman S, Saboeiro A. Fat grafting to the breast revisited: safety and efficiency. Plastic and Reconstructive Surgery 2007; 119(3):775–85.
2. Pierrefeu-Larange AC, Delay E et al. Radiological evaluation of breasts reconstructed with lipomodelling. Ann Chir Plast Esthet 2006; 51(1):18–20.
3. Rigotti G et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells. Plastic and Reconstructive Surgery 2007; 119(5):1409–22.