Fat grafting to the breast

Published on 23/05/2015 by admin

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Last modified 23/05/2015

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Chapter 7 Fat grafting to the breast

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History of Fat Grafting

The history of fat grafting goes back to 1893 when Neuber used it for facial defects.3 In 1895, Czerney used fat grafting for chest wall deformity post mastectomy.4 The early experimentation with fat grafting was not popular because, at a time when little was known about tumescent liposuction, most fat harvesting was performed by excision. The use of tumescent liposuction has given us the ability to harvest large amounts of fat with minimal donor site morbidity.

In 1987, Mel Bircoll published his work on fat grafting to the breast.5,6 The shortcomings of his work were poor long-term follow-up and a lack of mammographic studies as indicated by letters to the editor from 1987.7 American Society of Plastic Surgeons (ASPS) published a position paper in 1987 “Deploring the use of fat injection in breast augmentation” due to the fear of interference with breast cancer detection.8 The main concern at that time was that calcification from necrotic fat would cause interference with breast tissue evaluation by mammogram. At the same time published papers stated that surgical procedures such as breast reduction,9,10 augmentation11,12 and any breast procedure can also cause calcification. Further studies indicated that calcification from fat necrosis is easily distinguished from breast cancer calcification.1320

There was a long gap before any work was published on fat grafting to the breast. Dr. Coleman published his work on fat grafting to the breasts in 2007. His results were remarkable and showed long-term survival of the injected fat.2

In 2007, ASPS and The American Society for Aesthetic plastic surgery (ASAPS) jointly and strongly supported the ongoing research efforts that would improve the safety and efficacy of the procedure21 but also cautioned against fat grafting for breast augmentation.

The future of fat grafting depends on the establishment of a standardized harvesting, processing, injection technique, long-term follow up for safety and efficacy, and also establishment of a data base for all the fat grafting patients.

Principle of Low Pressure Fat Harvesting

Handheld syringe aspiration is accepted as a gentler technique for fat harvesting. There are no published data to support this claim. We at LSU division of Plastic and Reconstructive Surgery undertook the study to find out the negative pressure that is generated by handheld syringes and liposuction machines. The graph in Fig. 7.1 shows the in-situ maximum pressure within the 1, 3, 5, 10, 30 and 60 cc syringes. Negative pressures were measured in vitro and in situ with 1, 2, 3, and 10  cc pull on a 10 cc Luer-Lock syringe as well as a conventional liposuction machine at 254 mmHg, 381 mmHg, and 762 mmHg (Figs 7.1, 7.2, and 7.3).

The graph in Fig. 7.2 shows the negative pressure produced in a 10 cc syringe to be as high as 660 mmHg with full pull and 280 mmHg with only 1 cc pull on the 10 cc syringe.

The constant negative pressure at the low setting (254 mmHg) by a liposuction machine is 220 mmHg. This is less than the negative pressure in a 10 cc syringe only pulled back 1 cm3. Most liposuction machines have a control for adjusting the negative pressure.

In order to evaluate the extent of damage to fat cell caused by all harvesting techniques, lipoaspirant samples were analyzed using lactate dehydrogenase (LDH) and triglyceride levels (Fig. 7.4). Glucose-3-phosphodiesterase (G3PD) assay was used to measure cell viability (Fig. 7.5). LDH and triglyceride are intracellular components and their presence in the aspiration fluid indicates cell damage and cell wall disruption. The results suggests that the samples harvested with the low negative pressure liposuction machine were lower in LDH and triglycerides. The G3PD assay suggests cell viabilities were high in samples from the low-pressure liposuction machine in comparison to the handheld syringe, which indicates more viable cells by the low pressure technique.

Harvested fat cells were stained with fluorescent dyes for imaging using scanning electron and confocal laser electron microscopes (Fig. 7.6). The slides show the outer cell layers bursting from the negative pressure.

FIG 7.6 APPEARS imageONLINE ONLY

The low-pressure liposuction method removes the human factor and variation of the pull on the syringe and provides consistent negative pressure that helps to decrease operating room time and also prevents the surgeon’s hand fatigue. This technique yields large volumes of fat in a short period of time and minimizes the damage to the fat cells.

Autologous Fat Grafting to the Breast

In June 2008 at Louisiana State University Health Science Center in New Orleans, we started an IRB approved study on fat grafting to the breast. So far we have had more than 276 patients in this study and collection of the data has started for the follow up studies. Currently, fat grafting to the breast is a treatment option in conditions such as micromastia, breast ptosis, post mastectomy breast reconstruction, asymmetric breast, congenital malformation of the breast, and for treatment of complications associated with implant augmentation mammoplasty.

Technique