Thursday, April 2, 2009

Complications After Autologous Fat Injections to the Breast – an Article Review

Updated 3/2017-- all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

I reviewed a couple of articles on fat injections to the breast back in November.  Now I’ll like to review an article published in the January issue of the Journal of Plastic and Reconstructive Surgery  (PRS).  The full reference for the article is listed below.
The authors began by pointing out that autologous fat injection (fat grafting) to the breast has a history of being performed widely throughout the twentieth century, but  in 1987, the American Society of Plastic and Reconstructive Surgeons indicated that because of the side effects (i.e., tissue scarring, oil cysts, and calcification), autologous fat grafting to the breast might compromise breast cancer surveillance and should therefore be prohibited.  Most plastic surgeons stopped performing the procedure.  There were a few who continued to do the fat grafting to the breast and have published their results (several references given in this articles reference list).  As mentioned in the previous post, there are currently two clinical trials being done by Dr Scott Spear and Dr Roger Khouri. 
For any woman interested in being in one of the two clinical trials, you can find the information on the federal clinical trials Web site.

The authors had noticed that many of these breast augmentation procedures done using fat grafting are “performed incorrectly by untrained and untutored individuals.”   The paper was written to report on several cases of complications and to discuss the related issues.
The report is retrospective and involved 12 patients seen between 2001 and 2007.  The mean age of the women was 39.3 years.  All  the cases involved fat injections to the breast for cosmetic augmentation mammoplasty. The period from fat injection surgery to presentation ranged from 6 months to 6 years (mean, 3.25 years).   All of them presented with palpable indurations.  Others presented with pain (3), infection (1), abnormal breast discharge (1), and lymphadenopathy (1).   All patients were subjected to mammography, computed tomography, and magnetic resonance imaging to evaluate the injected fats.
Several cases were presented in detail with patient photos and radiographic photos, such as this one.
Case 2
A 37-year-old woman had undergone bilateral breast augmentation by autologous fat injection at a cosmetic clinic 3 years previously. Her breasts gradually became rigid and deformed, but she had no trouble with daily life. However, after having a child, she noticed an abnormal yellow secretion while breast-feeding. On her first visit to our facility, her breasts were clearly asymmetrical and deformed, and indurations were detected (Fig. 1). On mammography, computed tomography, and magnetic resonance imaging, large masses were detected in both breasts (Figs. 2 and 3). The tumors, which contained yellow fluid (Fig. 4), were removed surgically. Six months after the operation, both breasts were reconstructed with saline implants (Fig. 5). Abnormal breast secretion has not been observed since the masses were removed.
And this one (remember this study was done in Japan and I hope that the use of illegal silicone injection wouldn’t be done here in the U.S.)
Case 12
A 33-year-old woman underwent buttock liposuction and fat injection to the breast at a cosmetic clinic 2 years previously. After the operation, she became aware of indurations and disfiguration of both breasts and visited our facility. Asymmetry of the breasts and huge indurations were palpable (Fig. 18). On preoperative blood examination, high levels of antinuclear antibodies were detected. On mammography, huge masses were detected in the subcutaneous tissue (Fig. 19). Chest computed tomography revealed multiple low-density areas encapsulated with high-density areas in the subdermis in both breasts. Magnetic resonance imaging indicated multiple injected fat with high-iso signal intensity on T1-weighted images and low signal intensity on T2-weighted images (Fig. 20). Surgery to remove the subcutaneous masses was performed. Our routine examination for foreign bodies using nuclear magnetic resonance detected a small amount of silicone contamination. This suggests that the high levels of antinuclear antibodies in the blood may be the result of an immunologic reaction to silicone (human adjuvant diseases). These observations suggest that the patient had been injected with silicone at the time of surgery without her consent.

They give a very nice discussion of fat injection which includes some history
It appears that fat injection was first performed in 1893, when the German physician Franz Neuber9 used a small piece of upper arm fat to build up the face of a patient whose cheek bore a large pit caused by a tubercular inflammation of the underlying bone.
and continues to remind the reader of the virtual moratorium imposed in 1987, American Society of Plastic and Reconstructive Surgeons when the society recommended that autologous fat grafting to the breast be prohibited because of the relatively frequent occurrence of complications that compromised breast cancer screening.   They point out that this has resulted in little scientific literature or discussion on the procedure. 
As a result, there remains a dearth of studies examining the long-term safety and efficacy of this technique. This technology, especially with regard to its use in breast augmentation, must be tested by multi-institutional long-term studies with careful breast cancer surveillance.
They make the valid point the procedure continues to be performed even without good long-term outcome studies.
We believe that this has resulted in many victims, who are exemplified by the 12 patients that we have described in this article. The problems associated with this inadequately tested procedure are also exacerbated by a widespread decline in the skills of aesthetic surgeons because of the influx of many untrained and unskilled individuals, especially in some Asian countries, including Japan.

The complications associated with autologous fat grafting to the breast are well known, and include calcifications and oil cysts.  These calcifications may mask or cover the microcalcifications associated with carcinomas.  Remember fat grafting is “grafting” and there can be fat necrosis.

I admire their conclusions paragraph:
Autologous fat grafting to the breast is not a simple procedure and should be performed by well-trained and skilled surgeons. Patients should be informed that it is associated with a risk of calcification, multiple cyst formation, and indurations, and that breast cancer screens will always detect abnormalities. Patients should also be followed up over the long-term and imaging analyses (e.g., mammography, echography, computed tomography, and magnetic resonance imaging) should be performed.

Previous Post on Topic
Fat Injections for Breast Augmentation (November 6, 2008)

Complications after Autologous Fat Injection to the Breast;  Plastic and Reconstructive Surgery:Volume 123(1)January 2009pp 360-370; Hyakusoku, Hiko M.D., Ph.D.; Ogawa, Rei M.D., Ph.D.; Ono, Shimpei M.D.; Ishii, Nobuaki M.D.; Hirakawa, Keiko Ph.D


TanyaW said...

Interesting. Why is fat grafting ok for the face, buttocks, arms etc. But not for the breasts?

rlbates said...

The big issue with using it in the breast is the risk of the calcifications or scarring interferring with the diagnosis of breast cancer or putting the woman in the position of having "extra" biopsies to rule it out.

Anonymous said...

Re: rlbates

True, however, if you read other articles it is no more of an issue than silicone or saline implants any breast augmentation surgery requires women to get mammograms yearly aftewards. So this type isn't the only toput a women in the position to have to get mammograms. 1 out of 5 get saline or silicone rejected and they still need to be redone after 10 years. So both have risks. This is a new technology that needs to b perfected and done by highly trained professionals.

Anonymous said...

Information needs to be updated as I am sure that some progress has been made in the past several years.

rlbates said...

Anonymous (6/14/12), see the more recent post on fat grafting (6/10/12)