Commentary

Despite growing interest in the technique of fat grafting for breast augmentation, many plastic surgeons remain wary. To date, neither the American Society for Aesthetic Plastic Surgery (ASAPS) nor the American Society of Plastic Surgeons (ASPS) has revised its official public position statement of February 2007 advising that lipoaugmentation is not recommended to patients at this time.1, 2 Nevertheless, this excellent article by Delay et al presents an impressive experience with lipomodeling of the breast performed in France and a fine analysis of the various factors involved in successful outcomes. The authors have taken a responsible approach in emphasizing thorough patient education and informed consent. They have further acknowledged the need for more and longer-term research.

The ASPS Fat Graft Task Force (FGTF), in its recently published 2007 report,3 concluded that while “fat grafting may be considered for breast augmentation,” the quality of evidence supporting its safety and efficacy is by no means optimal. The FGTF's search of the literature could find no reports of randomized controlled trials involving fat grafting to the breast. Although the conclusions of the available literature are generally consistent and encouraging, the FGTF reported that the literature “consists mostly of case series, case reports, and expert opinion,” all of which are classified as lower-quality evidence. Therefore, there is no strong recommendation for this procedure coming from organized plastic surgery in the United States—only a grade B recommendation, stating that clinicians performing the procedure “should remain alert to new information and sensitive to patient preferences.” There is even less certainty regarding the evidence for specific guidelines when considering high-risk patients, although the FGTF consensus was that patients with risk factors for breast cancer should be approached cautiously and that a baseline mammogram (according to American College of Surgeons or American Cancer Society guidelines) should be obtained.

It is interesting that the public statements issued in 2007 by both the ASAPS and ASPS were somewhat stronger in their language than the FGTF's clinical recommendations to physicians. While the clinical recommendations of the ASPS FGTF essentially said “proceed with caution,” the public position papers stated explicitly that the procedure was not recommended at that time. Perhaps this reflects the concern that some practitioners without appropriate training and experience might be tempted to undertake lipoinjection of the breast as their latest practice enhancement tool, thereby putting unsuspecting patients at increased risk of complications. As Delay et al point out in their medical consent form (included as an Appendix to their second article in this issue of the Journal), satisfactory results in lipoaugmentation always depend on the skill and experience of the surgeon.

The authors stress the need for surgeons to adopt a standardized technique for lipoaugmentation and they provide suggestions based on their own vast clinical experience. In contrast, based on an objective review of the literature, the FGTF was unable to make specific recommendations regarding technique. High-quality research in both the clinical and basic science arenas is needed to definitively address the questions about what works best. Unless—and until—this is done, results of fat grafting will continue to vary widely.

One of the most important controversies surrounding fat injections to the breast, as pointed out by the authors, is the potential impact on cancer detection. Delay et al acknowledge that calcifications “are a normal consequence of lipomodeling and of any standard breast surgery.” In a retrospective examination of 17 grafting procedures to the breast performed from 1995 to 2000, Coleman and Saboeiro4 noted that postoperative mammograms showed changes that would be expected after any breast procedure. They concluded that concerns regarding fat grafting to the breast have been overstated and that the procedure should be approached “with the same caution and enthusiasm as any other useful breast procedure.”

Both the ASAPS and ASPS have warned the public that calcifications resulting from fat grafting to the breast can obscure or mimic breast cancer, making cancer detection more difficult. Yet the data on whether fat grafts interfere with detection are limited and, according to the FGTF, available data suggest that breast cancer detection and treatment actually may not be impaired. One such study,5 published in Aesthetic Surgery Journal, concluded that the appearance and evolution of patterns of fat necrosis in patients who have undergone fat injections to the breast are generally recognizable and often may be successfully followed-up with imaging alone. However, because calcifications may be expected as a result of lipoinjection to the breast, the authors of that study strongly recommended that women with a family history of breast cancer not undergo the procedure.5

Delay et al do not advocate that women with a personal or family history of breast cancer should automatically be excluded from having lipomodeling; in fact, 734 of Delay et al's reported 880 lipomodeling procedures were performed for breast reconstruction. However, the authors emphasize the importance of patient counseling and a thorough evaluation of each individual case before proceeding. Spear et al,6 in a 10-year, single-surgeon study of 37 breast reconstruction patients, concluded that lipoinjection in and around the reconstructed breast is a very safe technique that has limitations but is a good alternative to more complicated and riskier procedures to address significant contour deformities. A more recent study by Kanchwala et al7 involving a retrospective review of 110 breast reconstruction patients receiving fat grafting reached a similar conclusion.

Clearly, there is little if any concern that lipoaugmentation might cause breast cancer. The FGTF found no evidence suggesting this. It is acknowledged that changes in postinjection mammograms may be expected, and there are varying levels of concern on that issue. Regarding other complications, the FGTF listed a number of them associated with fat grafting in general, but did not find evidence that the incidence was “unduly high.” Specific to lipoinjection of the breast, a recently published study from Japan highlighted a variety of complications, including palpable indurations, pain, infection, abnormal breast discharge, and lymphadenopathy.8 Four of 12 reported cases had abnormalities on breast cancer screening. The authors concluded that patients must be advised of a variety of potential complications. They emphasized the necessity for long-term follow-up and imaging analyses using multiple modalities.

In the final analysis, we must give appropriate attention to the FGTF's finding of a lack of high-quality and long-term data on fat grafting of the breast. The experience of more than 880 lipomodeling procedures as reported by Delay et al—including follow-up on some of these patients for as long as 10 years—is extraordinarily important and enlightening, yet the further support of results from randomized controlled trials affirming both safety and efficacy is essential. Until such data become available, it is both prudent and necessary for national organizations and individual physicians, whether or not such physicians choose to perform lipoinjection of the breast in selected cases, to carefully advise patients that fat grafting for breast augmentation is a procedure that is still undergoing evaluation.