Patient Information Before Aesthetic Lipomodeling (Lipoaugmentation): A French Plastic Surgeon's Perspective

Identifying the Patient's Expectations 

Any gap between patient expectations and the practical limits of surgery may naturally affect the patient's satisfaction with the procedure.30 Benefits and limitations must therefore be made very clear beforehand. In particular, the patient must be told that fat grafting cannot totally replace breast prosthesis placement; the indications for the two procedures vary with the type of morphologic change needed (volume of the breast, underlying muscles) and with the donor site (volume of fat cells available for harvesting).

Because of these limitations, the surgeon must help the patient to reformulate any unrealistic, unattainable expectations. This is particularly true because the procedure, which combines liposuction of excess fat and augmentation of small-sized breasts, may appear very attractive and seemingly magical to many women; therefore, it could raise unrealistic expectations. Fortunately, today's patients are generally well–informed. They are able to access and understand the information now available through advances in communication, such as the Internet. They can usually verify the information given to them by the physician and assess its usefulness. They can also assess the quality of the explanations and care provided by the surgeon, along with his or her understanding of their needs. This is why it is crucial to provide complete, accurate, and timely information at every step of the procedure.

Analyzing Each Individual Case 

Indication for surgery is based on a detailed case history, on the patient's familial and personal medical history, and on a complete clinical investigation. Any personal or family history of breast malignancy should be evaluated in all patients undergoing plastic surgery of the breast. This information is critical not only to assess the indication for surgery, but also to decide whether a more in-depth preoperative evaluation should be provided. This is particularly important because patients with any history of breast malignancy are prone to fat cell necrosis and are at a higher risk of developing breast cancer.9

This focus on each patient's individual case is a crucial step of the procedure. The surgeon has a responsibility to provide the patient with accurate information about her status at the time of the visit; therefore, any sign or condition possibly interfering with the procedure or its result (and thereby influencing the final decision of the patient) must be taken into consideration and discussed. For instance, an important focal point is the volume of fat cells available for harvesting, which is often the limiting factor of the technique. Similarly, the indication for fat grafting will be discussed as a function of the initial shape of the breast: patients with breast ptosis who desire both mastopexy and augmentation can benefit from the procedure, but they must be aware that the degree of augmentation will be reduced, because most of the fat will be injected into the pectoralis major muscle and the upper breast quadrant to restore cleavage.

Providing Information on Different Treatment Options 

The Agence Française de Sécurité Sanitaire des produits de Santé—the French equivalent of the US Food and Drug Administration—recommends that the patients receive information on all available treatment options.31 In France, the most frequent alternative to fat grafting for patients who desire aesthetic breast augmentation is the placement of silicone gel–filled implants. The benefits and drawbacks of both options must be discussed and compared with the patient. Other options, such as saline or hydrogel implants, are also available (although they are less common) and must also be mentioned.

Describing the Major Steps of the Procedure 

A detailed description of the surgical procedure and treatment modalities must be given to the patient. This includes date and hour of hospital admission, one-day hospitalization (outpatient clinic), and general anesthesia. Apart from usual preoperative evaluation (biologic work-up and consultation with the anesthetist), a precise radiologic evaluation of the breasts (digital mammography and ultrasound) must be performed by an expert radiologist skilled in breast imaging and in the examination of augmented breasts. Whenever possible, preoperative and postoperative evaluations should be performed by the same radiologist.

Preoperative radiologic evaluation is essential to minimizing the risk of concomitant cancer in patients undergoing fat grafting. Images also serve as a reference for subsequent follow-up examinations. The precise data gathered from systematic pre- and postoperative work-up can be used for further retrospective studies and objective assessment of the technique. In the absence of suspicious findings, follow-up examinations will include only a digital mammography and ultrasound examination, at a frequency determined by the radiologist responsible for the one-year follow-up evaluation.

Describing Achievable Outcomes 

Fat grafting cannot completely replace breast prosthesis placement. The indications for the two procedures are different. Prosthesis placement is most appropriate for women who desire large breast augmentation and complete reshaping with round, firm, bulky breasts. Fat grafting is more appropriate for women who desire only moderate breast augmentation or those who simply want to restore their earlier contour (after weight loss, pregnancy, or breastfeeding). It is also recommended for women who wish to obtain more “natural” results, with no sensation of a foreign body in their breasts. Of course, the method is not an option in women who have insufficient fat deposits available for liposuction.

Consequently, as mentioned before, the surgeon must identify the patient's needs and expectations and make sure that she understands the possible limitations of the technique. In addition, the results of liposuction at the donor site are also a factor in the patient's overall satisfaction with the procedure. If she subsequently loses weight, her breasts may get smaller and she may become disappointed with the results locally. In such cases, it is important to emphasize the benefit obtained at the donor site (ie, the abdominal region or the thighs).

It is also important that the patient be aware of the degree of uncertainty associated with the results of the procedure. The fat cells grafted to the patient may not survive. It is generally necessary to account for approximately 30% fat resorption postinjection. In our experience, this rate is actually between 30% and 40%. To the patient, it may seem more like 50%, because she usually compares the final result with the volume of her breasts in the immediate postoperative phase, when the grafted site is swollen and edematous. (A comparison with preoperative photographs can help minimize possible patient disappointment with the results.) This is why the surgeon needs to mention the risk of further breast thinning and insist that the patient must maintain a stable weight postoperatively (because losing weight inevitably results in a loss of breast volume).

Describing the Risks and Complications 

French jurisprudence recommends complete information to the patient by the surgeon about all risks and possible adverse consequences of surgical treatments. This information concerns all risks known to the medical community that a reasonable patient would consider material to the decision of whether or not to undergo the procedure. These risks are, however, difficult to determine. Our current technique for aesthetic breast lipomodeling is relatively new. Moreover, although many surgeons performed lipomodeling in the past, relatively little has been published in the literature about fat grafting to the breast and its potential complications, in part because of the taboo previously associated with the use of fat grafting for breast augmentation.

It is usually the role of medical and scientific societies to provide updated information on the most common techniques. There is considerable information available and experts from scientific societies are the most likely to decide which information is relevant and should be made available to the patients. To fulfill that goal, experts must examine the different options with an objective and critical eye. Our experience with the different drawbacks and complications of breast lipomodeling is outlined below.

Postoperative Issues. Postoperative issues in lipomodeling are similar to those developing after liposuction, with patients complaining of pain, bruises, and swelling. Pain is mild and generally amenable to standard pain medication(s). The procedure causes inflammation and swelling, with a peak between 24 and 48 hours postsurgery. Most of the swelling resolves within one month and is completely (or almost completely) controlled within three months postoperatively. The patient must be informed that bruising will probably occur at both the donor site and at the graft site.

Complications. Serious complications of fat grafting are rare, as shown in procedures performed at other body sites.32, 33, 34, 35 Although it is the most common complication of surgery, hematoma is extremely rare in patients undergoing fat grafting to the breast. So far, none of the 850 patients treated by the first author (ED)—including all fat transfer indications—has ever experienced a hematoma.

The risk of pneumothorax is low. This complication has been reported in only one of our 850 patients who had undergone lipomodeling after postmastectomy latissimus dorsi breast reconstruction. Fat cells had been injected perpendicularly to the thorax wall to increase breast projection. The diagnosis of pneumothorax was confirmed radiographically after two episodes of oxygen desaturation (during and immediately after the surgical procedure). A pleural drain was inserted to restore normal saturation and the patient returned to her previous clinical condition, with no long-term consequences with respect to the results of lipomodeling. To prevent this complication, we recommend that fat grafting for improvement of periareolar projection should systematically be performed upward, in parallel with the chest wall, from two incisions made in the inframammary crease.

There is a theoretical risk, often put forward by detractors of the procedure, that fat cells can be injected in a vessel and cause fat embolism.36 To avoid this complication, it is advisable to use side-port cannulas and to perform injections while gently pulling the cannula off. No instance of fat embolism was encountered in our series of 850 patients.

The major short-term complication is infection. However, there have been exceptionally few reports of infection (principally at the graft site) in the literature published on fat grafting for other indications. Chajchir and Benzaquen34 reported no infection in their series of 253 patients. Of 145 patients treated by Fulton37 (corresponding to 399 injections), only three developed infection at the graft site. As for the 1350 patients treated by de Pedroza,35 infection developed in only one (overall infection rate 0.07%), which resolved after the administration of antibiotics. We consider the best preventive strategy against infection to be strict asepsis and proper antibiotic prophylaxis during the procedure. There may be signs of infection, with local redness in the breast area. Removal of the graft suture may result in the loss of a little murky, fatty fluid, but the reaction is generally successfully controlled with antibiotics and the local application of ice. Only six of the first author's 850 patients have developed moderate, transient superficial infection in the breast area. One had an infection in the umbilical area (near the liposuction site), but the local redness promptly resolved with antibiotic therapy and ice.

Long-term complications are mainly fat necrosis and irregular body shape at the donor site. Fat necrosis may occur when excess fat cells are forced into already saturated breast tissues, resulting in firm nodes possibly amenable to puncture. The radiologic aspect of necrosis varies from oil cysts to complex, multilocular, liquid or semisolid cystic masses, but necrotic lesions generally do not interfere with cancer diagnosis.38 Puncture generally yields a thick, yellowish, acellular fluid. Fat necrosis is less frequent when the procedure is performed by experienced surgeons. The incidence decreases from 15% with inexperienced surgeons to 3% with more skilled ones (several hundred cases or more), provided that the two major principles of the grafting procedure—namely, the use of a three-dimensional grid pattern and discontinuation of fat grafting when the tissues are saturated—are satisfied.1, 7

Defects at the donor area may be caused by the irregular suction of fatty tissue. This is why we recommend performing a minilipoaspiration that smoothes the area and increases the patient's overall satisfaction with the procedure. The experience acquired with liposuction is a valuable asset for minimizing the risk of complications and achieving the best aesthetic results possible. The current recommendations correspond to the practice of experienced plastic surgeons working in optimal surgical conditions. It must be kept in mind that breast aesthetic lipomodeling is a full-fledged surgical operation, that it deserves the same care and attention as other plastic surgery procedures, and that it must always be performed by a skilled plastic surgeon who is experienced with the technique.

Defective Results. When the indication is appropriate and the procedure is performed correctly, breast lipomodeling provides real improvement and generally achieves the postoperative results that patients expect (Figure 1). In some cases, a second session, under general anesthesia, is necessary to improve the shape of the breast. Experience with breast reconstruction and reshaping makes it possible to predict (or at least imagine) the final result. The number of sessions may vary and the volume of fat deposits available for collection may also vary within reasonable limits. When two sessions are needed, the patient should be informed beforehand to avoid misunderstandings and disappointment. Similarly, she should receive detailed information on the costs incurred in order to eliminate all potential sources of financial disagreement. In some rare cases, local defects may still be observed, including local undercorrection, mild asymmetry, or irregular shape. Again, a second lipomodeling session performed under local anesthesia can be attempted when the result is stable (three or four months postoperatively).

View Large Image Download to PowerPoint

Figure 1. A, B, Preoperative views of a 28-year-old woman with bilateral hypotrophy associated to moderate tuberous breasts. C, D, Twelve months after two lipomodeling sessions (first session: 250 cc to the right breast, and 90 cc to the left; second session six months later: 320 cc to the right and 210 cc to the left).

Addressing Fat Grafting and Breast Cancer Issues 

The Patient's Personal Risk of Developing Breast Cancer. In France, the risk for a woman to develop breast cancer is approximately one in 10.39 Breast cancer screening and diagnosis are therefore major issues.

The purpose of the initial work-up before lipomodeling is to confirm that there is no suspicion of breast cancer before initiation of the procedure, in order to minimize the risk of coincidence between cancer and fat grafting. Patients undergoing lipomodeling must be fully aware of their risk of breast cancer. The clinician can help them by using the Gail risk evaluation.40 They must also be aware that the breast imaging work-up performed before lipomodeling is essential in determining the risk of concurrent malignancy. In addition, all patients must make a commitment to undergo imaging follow-up at one, two, and possibly three years postoperatively, depending on the recommendations of the radiologist.

Finally, patients must be informed that, if they ultimately develop breast cancer, they will benefit from the same treatments as patients who are diagnosed under circumstances other than breast lipomodeling follow-up.

Risk of Cancer Dissemination Caused by Fat Grafting. The potential risk of dissemination of cancer cells by fat grafting is similar to the risk attributable to cancer biopsies. The first needle core biopsies of cancer lesions provoked similar debate and there are now sufficient data to show that the risk of cell migration is important, with some studies reporting rates of migration as high as 30%.9, 38, 41, 42 It has even been shown that cancer cells are able to migrate to the axillary lymph nodes, but with few clinical or prognostic consequences for the patients.43 The risk of displacement is principally related to the type of tumor and the time interval between biopsy and surgery. Other parameters, such as the volume or the grade of in situ or infiltrating carcinomas and lymph node involvement, have no significant impact on tumor cell migration.41 The most invasive cancers are actually infiltrating lobular carcinomas, infiltrating ductal carcinomas, and in situ carcinomas.41

Interestingly, the frequency of tumor displacement is inversely related to the time interval between biopsy and surgery. Sometimes, when patients undergo late surgery, no tumor cell is found.44 These data suggest that, contrary to sarcoma or ovarian cancer cells that may give birth to a secondary tumor at the site of injection, breast tumor cells displaced by the needle are fragile and do not survive after the procedure. No correlation has been shown between tumor biopsy and recurrence.45 It is clear from the literature that this mechanical transfer of cancer cells may lead to confusion in the interpretation of histologic data, such as the overestimation of the size of a small infiltrating carcinoma, the erroneous diagnosis of infiltrating carcinoma when cells from an in situ tumor are disseminated throughout the stroma, or even the erroneous diagnosis of lymph node involvement.

As is the case for biopsies, it is reasonable to think that cells detached from a small tumor undetected by preoperative work-up and displaced by fat grafting will not survive after the procedure. Breast cancer cells are fragile and the dissemination of cancer by lipomodeling is therefore very unlikely, as confirmed by the case of one of our patients who underwent fat grafting for breast reconstruction. At the time of the procedure a local recurrence was developing in this patient; this had gone undiagnosed in the preoperative work-up. The local recurrence was detected soon after the procedure, and a mastectomy was performed. Histologic examination of the surgical specimen revealed no dissemination of the tumor to other quadrants of the breast.9 These results should be confirmed on larger retrospective series of patients.

Contribution of Lipomodeling to the Early Detection of Breast Cancer. As is generally the case with breast surgery, lipomodeling modifies the structure and therefore the radiologic aspects of the breast. One of the most debated issues is the risk that fat grafting might confuse radiologic screening tests and hinder breast cancer detection.

In the authors' experience, this risk is very low. Only one of our patients developed a breast tumor and she was treated quickly.9 The procedure may even sometimes accelerate cancer detection because the patients undergoing lipomodeling are kept under strict radiologic control and close postsurgical follow-up.

There are three major concerns when performing fat grafting to the breast: technical considerations, follow-up modalities, and the management of postlipomodeling breast modifications. Very few authors have explored the technical aspects of the procedure or the outcome of the fat cells grafted to the patient using strict methodologic criteria.

There is no standardized procedure for fat grafting to the breast. Virtually every surgeon who performs this procedure uses a different technique.46 Very little research has been done involving a large clinical series and most reports on fat necrosis describe isolated clinical cases. In addition, postlipomodeling swelling cannot be systematically attributed to fat necrosis. In our experience, modern fat grafting techniques induce little or no fat necrosis.1, 7 As mentioned previously, the development of any such necrosis47 is probably a telltale sign of technical flaws during the procedure.

Whatever the technique or the clinical situation, careful breast monitoring is mandatory: clinical examination, surveillance of lesions (such as occurrence of skin wrinkles, shrinkage, or palpable lumps, nipple retraction, and diffuse inflammatory reactions) and signs of progression (such as a malignant lesion not resolving spontaneously). Mammography remains the most accurate tool for breast cancer detection and screening. Based on equivocal mammography or ultrasound findings, some studies have banned the use of fat grafting for breast augmentation on the grounds that calcifications and fat necrosis might delay or prevent cancer detection and treatment.48, 49 In reality, mammography is a very sensitive tool and radiologists can generally distinguish calcifications caused by surgery from those that are indicative of breast cancer.50

The clinical management of breast modifications is always the same, whether they occur after lipomodeling or in nonoperated breasts. The diagnosis of cancer must be confirmed histologically by percutaneous needle biopsy. Cytologic aspiration is simple and rapid, albeit with low sensitivity and specificity. Aspiration may yield acellular material of no diagnostic value and cannot be relied upon to determine tumor extension (either in situ or infiltrating lesions). Only needle biopsy can provide nearly as much information as surgical biopsy. This is why a needle biopsy should be systematically performed in all patients who present with swelling breast lesions or with atypical and probably malignant radiologic images. Our conclusion is that lipomodeling does not hinder early cancer diagnosis, especially when strict pre- and postoperative control is performed.

On the contrary, we believe that lipomodeling could facilitate cancer detection over time. Our hypothesis is that when the procedure is performed correctly, the mammographic density of breast tissues decreases and screening for breast cancer becomes easier, thereby allowing for earlier detection of the disease. This hypothesis is supported by radiologists who believe that “fat is their ally” because the fat graft remains radiologically clear, which greatly enhances contrast and facilitates the detection of abnormalities. Confirmation of this hypothesis should be obtained from a large-scale study focusing on this issue.

However, it should be impressed upon patients that radiologic examination of the breast has its limitations and, as reported in several of our patients,9 the absence of radiologic evidence of cancer (on mammography, ultrasound, or MRI) is not necessarily equivalent to the absence of cancer. Approximately 8% of breast cancer patients have normal mammographic findings51, 52 and 3% have both normal mammographic and sonographic findings.53

Protective Effect of Fat Grafting? Although we do not as yet have the observational evidence to prove it, our current research on fat-derived stem cells seems to indicate that these cells might exert some antitumor activity. If this intuitive expectation is confirmed by further study, it would show a possible protective role of fat grafting in defending against breast cancer. In addition, breast mammographic density is widely accepted to be an important independent risk indicator for the development of breast cancer54, 55, 56, 57 and even represents a risk factor for cancer in itself. It seems logical to assume that reducing breast tissue density by grafting fat cells may also help reduce the risk, probably via an indirect positive effect on stromal cells, which are known to be largely involved in the development of breast cancer.

Education of Breast Imaging Radiologists and Experts. Misinterpretation of the potential causal relationship between breast cancer and fat grafting is easy to understand. It is a common mistake to jump too quickly to conclusions based on outdated or erroneous information and there has long been a prejudice against fat grafting. The central issue seems to be the level of knowledge and training of experts and radiologists involved in breast imaging. On May 12, 2007 and June 7, 2008, two meetings that focused on breast imaging after plastic surgery and, more specifically, after breast lipomodeling (“Imagerie du sein et chirurgie plastique”) were organized in Lyon, France, for the purpose of sharing “best practices” among breast imaging radiologists. Experts unanimously confirmed that fat grafting to the breast is not responsible for errors or delays in breast cancer diagnosis. We believe that radiologists involved in the diagnosis of breast cancer (or of breast cancer recurrence when lipomodeling is intended for reconstruction after conservative cancer treatment) should be well-informed and trained specifically in the interpretation of breast images after fat grafting. Moreover, after a breast tumor has been diagnosed in a given patient, the radiologists should make sure that they introduce no unwarranted assumptions with respect to any causal connection between cancer and lipomodeling.

Experts in plastic surgery and oncology should also receive the same training. They must have a sufficient scientific understanding of lipomodeling to convincingly discount the controversies that will inevitably occur again on this issue (because cooccurrence between cancer and fat grafting is relatively frequent and because so many cancer patients feel depressed and view their situation as unfair), and to refute the suggestion of a relationship between fat grafting and the occurrence or recurrence of breast cancer. This point is particularly important because many people remain wary of the procedure; any hostile, unfriendly, or inappropriate word from expert professionals might aggravate a situation (ie, an occurrence of breast cancer or relapse) that is already stressful for the patient and would serve only to exacerbate their distress. It is essential to avoid unnecessary alarmism and to preserve the peace of mind of both the patients and the physicians involved.9

There is no reasonable basis to establish a correlation between the occurrence of breast cancer and a history of fat grafting to the breast. However, as the procedure is performed more often, the number of coincidences is obviously going to grow. This is why radiologists should be fully aware of the risk, be able to make an early diagnosis, and be able to adapt their communication accordingly.

Providing Information on Other Issues of Interest 

Microcalcifications. Calcifications are a normal consequence of lipomodeling2, 9, 10, 38 and of any standard breast surgery.23, 58, 59 A recent small series of 17 nonhomogeneous plastic surgery patients undergoing fat grafting for aesthetic enhancement or breast reconstruction found that 27% of patients had some sort of calcification.58 Whatever the surgical procedure, calcifications have no diagnostic or therapeutic significance and are usually noncancerous.23 There is no or little literature and virtually no systematic research on the occurrence of calcifications after lipomodeling. On the other hand, it has been shown that 50% of patients undergoing breast reduction surgery have calcifications within two years of the surgical procedure,23 but it has never been suggested that breast reduction surgery might interfere with cancer diagnosis. Calcifications caused by fat cell necrosis are easily recognizable; these usually benign, dystrophic calcifications are easily distinguishable from calcifications indicating breast cancer.23, 59 Three different studies conducted by our group have assessed the radiologic impact of fat grafting in patients undergoing breast lipomodeling after latissimus dorsi flap reconstruction10 for the correction of breast conservative treatment sequelae2, 9, 38 or for the correction of breast deformity. All three studies have shown that lipomodeling has no deleterious consequences for breast follow-up or radiologic detection of malignancies. As reported above, the conclusion of the two meetings in May 2007 and June 2008 was that there is no increased risk of missing the diagnosis of cancer after fat grafting to the breast when the procedure is performed by a skilled surgeon. On the contrary, some of the experts, as mentioned above, even reported that “fat is the radiologist's ally” because the fat graft remains radiologically clear, therefore enhancing the contrast and facilitating the detection of abnormalities.

Breastfeeding. There is currently no known contraindication to breastfeeding after fat grafting. Because the surgeon uses autologous fat cells similar to those present in the natural breast, there is no risk of functional changes that would forbid breastfeeding. However, it must be noted that there are no statistical data available to back up this information.

Describing Patient Follow-Up 

Patients must be aware of the necessity to have a complete imaging work-up before undergoing fat grafting in order to rule out the risk of concurrent malignancy. They must make a commitment to undergo imaging follow-up at one, two, and possibly three years postoperatively, as recommended by the radiologist. They must also arrange a visit with the surgeon after one year, making sure that the radiological follow-up has been correctly carried out.

Careful breast follow-up with complete clinical and radiologic examination of the breasts is mandatory, independently of the clinical context (aesthetic or reconstructive surgery).

Ensuring That Your Patient Fully Understands the Information Given 

In France, physicians are required to provide as much information as possible so that the patients can make an informed decision about their disease and treatments. In accordance with the code of public health, “all patients are entitled to receive information and must be given an opportunity to participate in their own healthcare decision-making. No medical decision can be taken and no treatment can be started without free and voluntary agreement from the patient involved. This agreement can be cancelled at any time” (law L. 1111-4, section 1).

Each patient must receive clear and unequivocal information sufficient to enable her to weigh the risk–benefit ratio associated with the procedure. To avoid hasty decisions, the law requires a “cooling-off” period before the patient can make any decision to participate. In accordance with French law, it is the responsibility of the surgeon to make sure that the patient fully understands the information delivered to her. How can surgeons show that the patient has both received and understood the information?

As acknowledged by the law, there are many possible ways of proving that the information has been correctly delivered: the number of preoperative visits, length of the “cooling-off” period, consultations with the attending physician, letters to the patient, information sheets, or an informed consent form signed by the patient. It is essential that the patients be given a written information sheet before undergoing fat grafting. It is also desirable that they sign a discharge form to show that they have both read and understood the specific information delivered to them. Signing the form serves as both a legal protection for the surgeon and as a psychological deterrent against further unjustified claims from the patient.

Providing an Accurate Cost Estimate 

As for any other plastic surgery procedure, French law requires that the surgeon provide a complete and detailed estimate of the costs incurred by patients. The estimate must also comply with all legal provisions relevant to the particular situation, notably the compulsory “cooling-off” period (15 days) between the drafting of the estimate and the start of the procedure. When a second session is necessary, the surgeon must produce a second estimate or, if the same document is used, the patient must give a second signature to confirm her agreement. Providing detailed and precise information on the costs incurred is useful for eliminating further sources of financial disagreement.