MUMMY MAKEOVERS IN SYDNEY & CANBERRA: BREAST AUGMENTATION
So far we have covered the basics of mummy makeover surgery at our clinics in Sydney & Canberra. This has included the options for the abdominal surgery depending on the extent of rejuvenation needed and of course the options for breast surgery. A topic I have left to cover on its own is autologous fat transfer for breast volume replenishment. This is a controversial topic and an evolving space. Often clinical practice can outpace the peer reviewed and established reliable patterns of clinical practice. In fact that is how most of medical and other scientific innovations came to become the new norms. With regards to fat transfers it is the holy grail of breast augmentation and reconstruction approach. The closest thing to the Golden rule set forth by Sir Harold Gillies of replacing like with like. Sure the fat is not exactly modified apocrine gland but it feels the closest to normal breasts. This is the premise behind microsurgical reconstructions taking abdominal fat on its blood supply to the chest for reconstruction. So lets take this one step further what if we did not have to do hours of microsurgery with the large incisions and the complication profile to achieve the same ends. That is soft natural breast mound that for all intents and purposes is the same as normal breast tissue to touch. In fact the first breast augmentation was performed by Czerny in the 19th century by moving a lipoma ( benign fat growth) from a patient’s back to their chest wall.
So here is where things stand, this is from my recent textbook chapter on breast augmentation:
Autologous Fat Grafting
Fat grafts have become a popular means of soft tissue augmentation and breast reconstruction in recent years. Capitalising on the benefits of pluripotent STEM cells from adipose tissue remains the Holy Grail of tissue engineering and regeneration. Initially, Coleman et al. injected fat into the face and then used to same technique to inject into the breast. Bircoll was first to note calcifications in the breast post fat grafting. That same year, these concerns prompted the American Society of Plastic Surgery to ban its use. Fat necrosis microcalcification could mimic calcifications associated with breast cancer. This could result in patient distress and high false positive reporting of breast cancer on mammography. As imaging modalities have improved in the 21st century this concern has been dispelt with the appearance of breast cancer calcification was noted to be speculated compared with the benign egg shell shaped appearance of fat necrosis. The American Society of Plastic Surgeons have since overturned their previous decision and the number of procedure have increased internationally.
The benefits of fat grafting is diverse, ranging in the reversal of the effects of radiotherapy post breast cancer surgery and scar contracture from burns to an adjust for minor defect correction in breast augmentation. Its use has also been described for women who have undergone breast conserving surgery and total mastectomy. There have been many changes in recent years with better understanding of fat and stem cells as well as better techniques for harvesting and engrafting. However, following recent concerns regarding BIA-ALCL (Breast implant Associated- Anaplastic Large Cell Lymphoma) in women who have breast implants there is an unknown risk regarding the introduction of stem cells from fat cells and lymphoma proliferation. Seth et al. led a comparative study of women who had prosthesis combined with autologous fat grafting as an adjunct, versus women who had implants only. He did not find an increase in the recurrence risk of breast cancer. This is reassuring to those having implants and fat injection.
Due to fat graft loss from reabsorption, fat necrosis and cyst formation, its efficacy remains to be seen. Rohrich et al. explored the efficacy of centrifugation to improve the quality of graft and determined that centrifugation did not improve viability. Cell enrichment techniques involve the separation of fat into two distinct layers prior to injection: mature and immature fat cells. The latter having been yielded by placing fat cells in stroma with collagenase during a period of centrifugation. Other methods include gravity separation, washing, gauze rolling, and filtration. Washing and gauze rolling may result in a loss of stromal vascular fraction which may contain growth factors which allow differentiation of preadipocytes to adipocytes.
Imaging studies which have explored fat graft retention rates over time have noted graft retention volumes of 0-43%. Rates may be lower post breast cancer surgery with radiotherapy and higher in cases of breast augmentation where women have native breast tissue. The improved vascularity of the recipient bed and ability for nutrient tissue from the surrounding area, to supply the graft, would be greater than in areas of radiotherapy damage.
Smaller amounts of fat grafting volumes (10-100 mL) can be a useful adjunct to improve the transition from chest wall to implant and to conceal rippling. In this manner, fat can be grafted into the decollete and cleavage area, lateral hollows behind the mid-axillary line and implant fold. Cohort studies have shown a decrease of capsular contracture (Bakers grade from 4 to 1) using a single fat grafting session. Results were recorded at 20.3 months follow up. The same manuscript noted avoidance if implant exposure in four patients by using fat grafting compared to a control group who had not had fat grafting.
The BRAVA external expander device was on the market for 10 years, has been theorised to exert an isotropic distraction force on the breast resulting in an expanded fibrovascular scaffold, which is fertile ground for fat engraftment. A multicentre study of 488 patients who used the device showed promising results visually as well as through the clinically reported data. A mean augmentation volume of 233 ml is reported at 12 months based on 3D calculations. The patients had a baseline MRI preoperatively, a 3-month and a second follow up MRI at least 6 months postoperatively. The key findings were a stable volume between the first and second postoperative MRI, indicating permanency of fat graft. The fat graft retention rate was not explored as percentage augmentation was deemed to be a more suitable measure of assessment. Percentage augmentation is only a meaningful measure in women who have native breast tissue and are undoing augmentation for additional volume. It is likely to be an inaccurate measure in women who have had a total mastectomy and radiotherapy who are not being augmented, but are undergoing breast reconstruction. The BRAVA device has since been removed from the market.
ACHIEVING SUCCCESSFUL MAKEOVERS WITH BREAST AUGMENTATION
When measuring breast volume, there is equivalence between 3D laser scanning and MRI for volume measurement and these modalities have also been shown to be useful when planning complex reconstruction to establish breast volume asymmetry, volume necessary to inject for correction and to monitor fat graft retention rates over time.
The usefulness of external expansion devices (eg BRAVA device) appears to be in cases where women have native breast tissue which is more responsive to the negative pressure. In case where women have undergone breast conserving surgery, or total mastectomy and adjuvant radiotherapy, it appears to be less efficacious. However, autologous fat grafting appears to reverse the deleterious effects of the radiotherapy making the skin supple and pliable.
When used for breast reconstruction autologous fat grafting can assist with volume correction for minor defects in lumpectomy sites, post sector resection in breast conserving surgery and for reconstruction post total mastectomy. Larger controlled augmentation volumes remain in the realm of promising trials and are becoming more popular.
SYDNEY & CANBERRA BREAST AUGMENTATION FOR MUMMY MAKEOVERS
The message is fat does reabsorb, it is useful for small contour deficits, implant rippling, cleavage areas, minor augmentations in the upper pole and to a lesser extent for consideration is an option for primary augmentation judiciously and is the future.