Plastic & Reconstructive Surgery:
Breast: Original Articles
Trends in Autologous Fat Grafting to the Breast: A National Survey of the American Society of Plastic Surgeons
Kling, Russell E. B.A.; Mehrara, Babak J. M.D.; Pusic, Andrea L. M.H.S., M.D.; Young, V. Leroy M.D.; Hume, Keith M. M.A.; Crotty, Catherine A. M.P.H.; Rubin, J. Peter M.D.
Pittsburgh, Pa.; New York, N.Y.; St. Louis, Mo.; and Arlington Heights, Ill.
From the Department of Plastic Surgery, University of Pittsburgh; the Department of Surgery, Memorial Sloan-Kettering Cancer Center; Body Aesthetic Plastic Surgery & Skincare Center; and the American Society of Plastic Surgeons.
Received for publication December 20, 2012; accepted January 30, 2013.
Disclosure: The authors have no commercial associations or financial interest to declare. The authors have no conflicts of interest to disclose.
J. Peter Rubin, M.D., Department of Plastic Surgery, University of Pittsburgh School of Medicine, 4553 Terrace Street, 6B Scaife Hall, Pittsburgh, Pa. 15261, firstname.lastname@example.org
Background: Autologous fat grafting has been gaining popularity in recent years, although there remains concern regarding the safety and efficacy of the practice for breast surgery. The purpose of this study was to determine national trends for fat grafting to the breast and to establish the frequency and specific techniques of the procedure to provide more supportive data.
Methods: A questionnaire was e-mailed to 2584 members of the American Society of Plastic Surgeons. Variables included prevalence and applications of fat grafting to the breast. Components of the fat graft protocol were also assessed.
Results: Four hundred fifty-six of the 2584 questionnaires were completed. Sixty-two percent of all respondents reported currently using fat grafting for reconstructive breast surgery and 28% of all respondents reported currently using the practice for aesthetic breast surgery. The most common reason cited by respondents for using fat grafting to the breast was as an adjunctive therapy to implant or flap surgery.
Conclusions: Fat grafting to the breast is a common procedure most often used in reconstructive operations. The increasing prevalence of fat grafting to the breast indicates a need for collection of clinical data and supports the establishment of a national prospective registry to track outcomes after aesthetic and reconstructive applications.
Autologous fat has been used for over a century to enlarge and reshape breasts. Czerny, in 1895, was the first to describe autologous fat transplantation to the breast, when he transferred a lipoma from the dorsal flank region to correct a breast defect.1 The 1950s saw a decreased interest in autologous fat transfer after Peer demonstrated only a 50 percent graft survival rate at 1 year.2 However, with the introduction of liposuction by Illouz in the late 1970s, there was a renewed interest in autologous fat transfer,3 especially as the development of tumescent liposuction led to more widespread practice of lipoplasty.4 Interest in injecting aspirated fat quickly followed the genesis of liposuction techniques.
Fat grafting to the breast provides the ability to shape and contour tissue through a minimally invasive approach, although early interest in this technique was tempered by a cautionary statement from plastic surgery society leadership in 1987. The American Society of Plastic and Reconstructive Surgeons Ad-Hoc Committee on New Procedures stated: “The committee is unanimous in deploring the use of autologous fat injection in breast augmentation.”5 The committee was concerned that graft interference with mammography and physical examination warranted the exclusion of the technique from clinical practice altogether. Their concerns were based on the perceived notion that fat grafts would eventually calcify and form scar tissue and that these changes would lead to difficulty in differentiating between benign findings and those suspicious for malignancy. In 2009, the Fat Grafting Task Force of the American Society of Plastic Surgeons examined evidence in the literature and published a report that recognized that fat grafting, including treatment of the breast, was being used in clinical practice and that more data should be collected.6 Although the committee did not discourage the procedure, they did not provide any formal treatment recommendation.
Fat grafting to the breast has become a frequent topic of discussion at regional and national plastic surgery meetings. There remains much debate about optimal processing methods for large-volume grafting, especially when commonly used techniques were originally developed for small volume grafting.7 Innovative methods of treating the recipient site with external expansion have been pioneered and published.8–10 In addition, there have been clinical reports of admixing graft material with adipose-derived stem cells.11,12
The purpose of this study was to benchmark current practices in both aesthetic and reconstructive fat grafting to the breast through a survey of the American Society of Plastic Surgeons. The survey was designed to assess specific applications of fat grafting to the breast, harvest and processing methods, and frequency of procedures among plastic surgeons. We hypothesized that fat grafting to the breast would be reported as a common procedure.
A questionnaire was randomly e-mailed to 2584 members of the American Society of Plastic Surgeons. The questionnaire was generated using surveymonkey.com software and mailed from a plasticsurgery.org e-mail account. The survey was sent out three times to increase response rate. Instructions were included in the cover letter, with a link directing participants to the survey. Participation in the survey was voluntary and participants could exit the survey without submitting their responses at any time. No participant compensation was provided. The survey contained multiple-choice questions and five-point Likert scale questions separated into (1) demographics, (2) practice patterns, and (3) potential obstacles (Table 1). All responses were collected and saved on secure surveymonkey.com servers for future analysis. A descriptive analysis (mean, frequency) was performed.
A total of 2584 members of the American Society of Plastic Surgeons received the questionnaire, and 456 questionnaires were completed (18 percent response rate). Respondents were from all nine geographic areas of the United States (Tables 2 and 3). Eighty percent of all respondents reported currently performing fat grafting for nonbreast applications (Fig. 1). Seventy percent of all respondents reported having ever performed autologous fat grafting to the breast. Surgeons reported that, 64 percent of the time, they bring up the topic of fat grafting during a patient consultation, rather than the patient initiating the discussion (Fig. 2).
Autologous Fat Grafting for Breast Reconstruction
Sixty-two percent of all respondents reported currently using fat grafting for reconstructive breast surgery. (Fig. 3). In the past 12 months, over half of these respondents performed one to 10 cases and 6 percent performed 26 to 50 cases. The most common applications among respondents using fat grafting for breast reconstruction were as an adjunct to implants to disguise border or device and/or provide better shape (98 percent), adjunct to tissue flaps for improving shape or correcting contour of flaps (96 percent), and lumpectomy defects (87 percent) (Fig. 4).
Autologous Fat Grafting for Aesthetic Breast Surgery
Twenty-eight percent of all respondents reported currently using fat grafting for aesthetic breast surgery. (Fig. 5). In the past 12 months, over half of these respondents performed one to 10 cases and 4 percent performed 26 to 50 cases. The most common applications among respondents using fat grafting to the breast for aesthetic applications were as an adjunct to implant augmentation to disguise border or improve shape (72 percent), as an adjunct to mastopexy (68 percent), and congenital deformities (e.g., tuberous breast) (62 percent) (Fig. 6). Of note, 59 percent of all respondents have never performed fat grafting for aesthetic breast surgery and have no plans to perform it in the future (Fig. 5).
Harvest, Processing, and Handling for Fat Grafting to the Breast
The most preferred site for harvest was the abdomen (76 percent). A small proportion (5 percent) reported injecting fat that had been previously frozen or cold stored. The preferred harvest technique was handheld suction (55 percent) (Fig. 7). When asked what techniques they use for lipoaspirate processing (without exclusivity), 34 percent reported using a centrifuge step and 34 percent reported using a filter step (Fig. 8). Twenty-eight percent of respondents reported using a wash or rinse step. Five percent of respondents used fat additives before reinjecting the lipoaspirate (Fig. 9). Handheld syringe was the most common (97 percent) method of reinjection. Eight percent of surgeons use external expansion with the Brava device (Brava, LLC, Miami, Fla.) (Fig. 10).
Obstacles to Implementation into Clinical Practice
Participants were also asked to rate potential obstacles to the incorporation of fat grafting to the breast into clinical practice. Fifty-two percent of respondents strongly agreed or agreed that poor fat graft retention rates and/or unreliable results are obstacles, whereas 50 percent strongly agreed or agreed that interference with mammography and cancer screening is an obstacle. In addition, 49 percent strongly agreed or agreed that the lack of evidence concerning the impact of fat grafting to the breast on breast cancer risk or recurrence is an obstacle. However, only 35 percent strongly agreed or agreed that lack of training is an obstacle (Table 4).
According to the American Society of Plastic Surgeons, breast augmentation accounted for over 307,000 operations in 2011.13 Like all surgical procedures, breast surgery can be associated with adverse events.14 Fat grafting may have a role in improving clinical outcomes for breast surgery as an adjunctive therapy or as a primary therapy.
Based on our study, it is clear that plastic surgeons are actively performing autologous fat grafting. Seventy percent of all respondents reported having ever performed autologous fat grafting to the breast. Responding plastic surgeons most preferred to use fat grafting to the breast for reconstructive rather than for aesthetic applications (62 percent versus 28 percent). The reconstructive penchant of plastic surgeons may be explained by the higher prevalence of asymmetry and contour defects in patients undergoing reconstructive breast surgery, which can be mitigated with fat grafting. This technique, demonstrated by de Blacam et al., has been shown to effectively correct “stepoff” deformities in the superomedial area of the reconstructed breast.15 The grafting of fat can also be used to treat irradiated breast tissues and potentially prepare the bed for implant-based reconstruction.16,17 It has likewise been noted by Rigotti et al. that fat grafting can soften capsular contracture.18 Some have also noted that fat grafting improves postmastectomy pain syndrome.21
Surgeons preferred to use the technique as an adjunct therapy, and this was more pronounced in reconstructive breast surgery. This preference may be explained by the ability of surgeons to improve the results of traditional breast surgery procedures using this technique, without changing the general treatment paradigm. As a complement to the primary method of surgery, fat grafting has shown success in transverse rectus abdominis musculocutaneous and latissimus dorsi flaps and in implant-based procedures.20–23 Fat grafting certainly has promise as a primary treatment method in place of more traditional procedures. It has been used successfully as a primary method of treatment in the case of lumpectomy defects, with a greater than 90 percent satisfaction rate reported in this patient population.24 Another situation where fat grafting has been used as the primary treatment is in the case of tuberous breast deformities; however, few responding surgeons are using the technique for this deformity.7 Some have also used fat grafting as the sole surgical treatment for Poland syndrome.25,26 As a primary means of breast reconstruction, Rigotti et al. demonstrated that the relapse rates and disease-free period after fat grafting were comparable to controls. That study concluded that primary breast reconstruction with fat grafting not only is efficacious but also is a safe alternative.27,28 Delay et al. suggested that primary breast reconstruction with fat grafting should be reserved for patients with small breasts or for the repair of reconstruction failure.20
It is interesting to note that fat grafting for cosmetic purposes is not as prevalent as reconstructive use, likely because of the reliability of standard augmentation techniques in healthy tissues. Despite the potential benefits, 59 percent of all respondents have no future plans to incorporate this technique into clinical practice for aesthetic breast surgery. Coleman and Saboeiro reported their experience with fat grafting for breast augmentation and showed significant long-term volume retention and patient satisfaction.7 Del Vecchio and Bucky used fat grafting with external expansion for cosmetic augmentation in 25 patients and demonstrated a significant increase in volume at 6 months, but without oil cysts or breast masses (as measured by magnetic resonance imaging).8 Khouri et al. published their experience using external expansion and fat grafting for cosmetic purposes and demonstrated a strong linear correlation (R2 = 0.87) with pregraft Brava expansion and the resultant breast volume.9 The role of external expansion is still evolving, and only 7 percent of respondents report using the method both before and after grafting.
Our survey demonstrated that surgeons who perform autologous fat grafting to the breast agree on certain aspects of technique. The abdomen was the preferred harvest site for a majority of responding surgeons. Most responding surgeons used a handheld device or a suction device for their harvest method. These results mirrored those of Kaufman et al. on patterns of autologous fat grafting.29 Although harvest site is consistent among most surgeons, processing is less uniform. Only 34 percent of respondents centrifuged the fat, and 55 percent used a handheld suction device; both are constituents of the Coleman processing technique. Certainly, centrifugation is but one of many methods for separating the aqueous layer from the fat.30
Although most surgeons reported using no additives before reinjection, a small minority responded that they incorporate various additives to the lipoaspirate. Although many researchers have shown promising results using autologous stem cells and fat grafting, no controlled human studies exist.10,11 An additional minority of surgeons reported freezing or cold storage of fat (5percent); however, in 2009, the American Society of Plastic Surgeons Fat Grafting Task Force reported that graft viability decreases after freezing or cold storage and thus recommended using fresh fat instead.6 There are many diverse opinions surrounding the harvest and processing of fat, with little uniformity in the clinical arena of breast surgery. The lack of objective data for fat grafting to the breast could explain the different processing methods. Thus, continued research is needed to establish criterion standard methodologies for maximizing fat graft retention and overall patient satisfaction. This standardization may also increase the potential applications of the technique and may lead to increased prevalence in clinical practice. It should be noted that survey data, while representative of practice patterns, should not be construed as evidence supporting these practices.
Most surgeons cited the impact of fat grafting on breast cancer risk or recurrence to be an obstacle. This is a question that will only be answered through the analysis of large groups of patients over time with careful cancer screening; however, currently available studies suggest that there is not an increased risk of cancer.7,20,27 There are concerns that fat grafting may impede cancer screening (by mammography) because of calcification and cyst formation, which may appear on screening mammography and can be suggestive of a malignancy.31 A blinded mammography comparison study by our group showed that radiographic changes caused by fat grafting were less severe than those seen with reduction mammaplasty patients, with a significantly lower Breast Imaging-Reporting and Data System score.32 In addition, others have shown that there is no statistically significant difference between breast density findings before and after fat injection, whether using the American College of Radiology classification or a personalized rating system.33 Breast ultrasound is also an effective screening tool for tracking changes following fat grafting.34
Current trends show that fat grafting to the breast is almost as popular as fat grafting for nonbreast applications. Surgeons prefer to use the technique in reconstructive cases and most often as an adjunctive therapy. A similar trend of adjunctive use was seen for fat grafting in aesthetic breast surgery. These trends may continue as more research and safety and efficacy data are accumulated. Part of this research should focus on developing standardized protocols for harvesting and processing the fat, standardizing a screening mammography regimen, and examining the risk of malignancy after fat grafting. Because of the increasing prevalence of patients with fat grafting to the breast, the collection of clinical data and the establishment of a national prospective registry to track outcomes after aesthetic and reconstructive applications are recommended.
This work was supported in part by National Institutes of Health grant R01 CA114246 (to J.P.R.).
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