Breast augmentation is one of the most popular cosmetic surgical procedures among women everywhere. Although using fat injections for breast enhancement has waned in popularity over the years, it is again coming into the limelight. Due to advances in science and technology as well as a better understanding of what’s involved, women again have the option of a more natural method of breast augmentation: with autologous fat transfers.

According to statistics from the American Society of Plastic Surgeons, breast augmentation was the most popular surgical procedure in 2011 in the US—the world’s largest cosmetic procedures market.

For a long time, the most widely used method of breast augmentation was artificial implants—containing saline or silicone. The next option was breast enhancement using flaps of tissue taken from or moved from other parts of the body. In fact, 2012 marks the 50^th anniversary of the first silicone implants. Injectables, as in dermal fillers, never really caught on in breast augmentation even though they have grown tremendously in other areas including facial, neck and hand rejuvenation.

Although using fat as the foundation for breast enhancement waned in popularity over the past decade, it appears to be again coming into the limelight. Thanks to advances in science, technology and methods in harvesting, processing and injecting, women again have the option of breast augmentation with autologous fat transfers.

What is an autologous fat transfer?

An autologous fat transfer is the process in which fat cells from one area of the body are transferred to another. The process is also referred to using the terms fat transplantation, fat grafting, lipofilling or lipoinjection. Using autologous fat transfer in breast augmentation is sometimes referred to as breast fat grafting or BFG.

From its early days autologous fat transfer for breast augmentation sounded like a great idea—who wouldn’t want to get rid of fat from places where its unwelcome and have it enhance their breast size? As a filler, fat has an edge over all other fillers ever invented because it is natural, biocompatible, readily available and inexpensive. Fat has the potential to offer long lasting results if grafted fat cells are able to develop a healthy blood supply. However, the history of autologous fat breast enhancement clearly shows that the procedure and its outcomes are not so easy or that straightforward.

The history of breast augmentation with autologous fat

The first recorded use of autologous fat injections was in 1893 by the German physician Franz Neuber who used fat from the arms of a patient to augment facial depressions in the cheeks. Karl Czerny, another German physician, used autologous fat in breast augmentation two years later, in 1895.

By around the 1950s, although autologous fat transfer to augment breasts was available, the rate at which the fat was reabsorbed into the body (reabsorption rate) was so high—even as much as 100 percent—making the outcome unpredictable if not completely useless. With improvements in technology, the procedure gained popularity again by the 1980s.

Despite the growing popularity, a number of factors worked against it becoming a mainstay in the breast augmentation field. Breast augmentation was found to lead to complications such as infection, death of fat cells (fat necrosis), cyst formation (liponecrotic cysts), and calcifications and as well as high fat reabsorption rates.

Calcium build-ups in the breast tissue, referred to as micro and macro calcifications, were observed in women who received autologous fat injections to their breasts. Development of oil cysts and tissue scarring was also common. Oil cysts form when oil debris from damaged fat cells creates tiny pools of oil, which then become surrounded by other cells. These cyst walls can then become calcified.

Soft tissue changes occurring in the breasts following fat augmentation were setting off false alarms when mammograms were being performed. They were causing many unnecessary biopsies being performed, just to rule out malignancies. Concerns were being raised about how the results of fat grafting may be interfering with the detection of breast cancer; the late detection of which can have deadly consequences while early detection can save lives. In 1987, the American Society of Plastic and Reconstructive Surgeons (ASPRS) Ad Hoc Committee on New Procedures unanimously condemned fat grafting to the breast citing concerns that potential scarring and calcifications may interfere with the detection of breast cancer.[1]

Although fat grafting waned in the US, research continued elsewhere. In 2007, the American Society of Plastic Surgeons formed a Fat Grafting Task Force to address key aspects of fat grafting, specifically to the breast. Besides the (then) current and potential applications, the task force looked at risks and complications, how technique can affect outcomes in terms of safety and efficacy, risk factors to be considered in patient selection and advancements in research and molecular biology that have the potential to impact current or future methods of fat grafting.

The task force concluded that fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgeries. It also reported that results of fat grafting were dependent on technique as well as expertise of the surgeon—a piece of information that has timeless value to potential patients.

Where are we now?

The key issues that prevented the progress of breast fat grafting are slowly being resolved.

Radiologic evidence shows that it is not difficult to distinguish between calcifications occurring after fat grafting and micro-calcifications suggestive of breast malignancy.

A study published in the Plastic and Reconstructive Surgery in 2011 March concludes that “Radiographic follow-up of breasts treated with fat grafting is not problematic and should not be a hindrance to the procedure.” However, the authors suggest “…radiographic follow-up of women undergoing breast lipomodeling should be standardised to ensure reproducibility and improve patient safety”.

A systemic review on Autologous Fat Grafting for Primary Breast Augmentation published in the Aesthetic Plastic Surgery journal in April 2011 by a team of researchers from the University of California, states that “…no reports suggests an increased risk of malignancy associated with fat grafting.”[2]

In fact, there is mammogram evidence that more calcifications occur after breast reduction than after fat grafting.

The conclusion—that fat grafting is effective and safe in terms of cancer surveillance—clears the way for women who would prefer a more natural type of breast augmentation using their own fat, over the option of breast implants. This is especially true for women who have no history of breast cancer.

Within the context of breast implant scares, the whole PIP implant fiasco and the growing trend towards more natural and subtle enhancements, autologous fat breast enhancement appears to have a great future ahead.

Costhetics interviewed Dr. Daniel Del Vecchio, a consulting plastic surgeon at the Harvard’s Massachusetts General Hospital, who was in Darwin to present a paper on evidence based breast surgery at the 35^th Annual Conference of the Australasian Society of Aesthetic Plastic Surgery (ASAPS). If the elective breast augmentations market is hot, according to Dr. Del Vecchio, the autologous fat transfer segment is even hotter.

Del Vecchio asserts: “Every year more than 300,000 women in the U.S. pay to have incisions on their bodies and breast prostheses inserted that may last ten years. In 2011 this figure was 307,000. And we know that there are over 40 million women in the U.S. who buy padded bras each year. This means that for every one patient that elects to have implants there are over 100 women who wish their breasts were larger, but many of them reject breast augmentation with implants as an option.”

He argues that for women who want bigger breasts, fat grafting offers a natural augmentation with broad appeal. This patient segment, he believes, is “waiting for an option beyond saline or silicone implants.”

That option is becoming better and better as new developments in technology and better understanding of the intricacies involved continue to improve success rates, volume maintenance over time and capacity for large volumes.

Better know how, techniques and technology

Studies show that using refined techniques to minimise trauma to fat cells during harvesting, processing, and re-injection can lead to favourable long term results. Research continues in search of better methods of fat removal for minimising damage to fat cells. Using centrifugation for isolating viable fat cells from oil, water, blood and other debris helps improve success rates and reduces potential complications.

The skills and experience of the surgeons matter in fat grafting to the breast; just as it matters with any other cosmetic procedure. Although fat survival rates may vary within a broad range, between 20 to 70 percent in the hands of the average surgeon, highly skilled and experienced surgeons consistently achieve survival rates around 80 to 90 percent. This is a dramatic improvement when compared to less than 50 percent survival rates thirty years ago. There is a common agreement that standardising procedures will go a long way towards improving success rates even further.

Injecting fat into the breasts in micro droplets helps improve fat survival and procedure success rates. According to Dr. Del Vecchio, experience has shown that fat grafted breasts consistently maintain volume at six months, a year, three years and five years post graft. Surgeons agree that the volume after six months will generally remain in the long term.

Experts are still not agreeing on the ideal location on the breasts for injecting fat—research is ongoing to discover whether injections should be to the superficial fat layer, beneath the mammary glands or into the muscle.

What is the future?

How big can you go with fat?

Although fat grafting on its own can only deliver moderate volume gains, techniques that use pre-expansion of the tissue before fat grafting can result in doubling of original breast volume or an augmentation of 250 cc on average.

Dr. Del Vecchio was the lead author of a study that took place between 2007 and 2009 involving 25 patients (46 breasts) treated with fat grafting for breast augmentation coupled with pre-expansion using something called the BRAVA device. He says that all of the women showed a significant increase in breast volume, which ranged between 60 to 200 percent after six months, according to magnetic resonance imaging. All had breasts that were natural in appearance and soft to the touch. Also, MRI exams did not show any new oil cysts or breast masses.[3]

The conclusion of the study was that pre-expansion of the breast allows for mega volume grafting, which is defined as over 300cc. The results were reproducible, long-lasting and were achieved in less than 2 hours. This finding, about the ability to achieve mega volumes, conveniently puts a lid on the objection against fat grafting for breast augmentation that it can only provide modest volume increases.

Stem cell enriched fat grafting

Among other factors, the fat survival rates in fat grafting depend on the blood supply to the injected cells. Without a good blood supply to sustain them, injected fat cells are unable to survive or thrive. One way of ensuring a good blood supply is harvesting naturally occurring stem cells from the fat tissue, combining them with growth factors and transplanting them back into the breast by combining them with fat.

A device for processing and activating stem cells is already in the market—from Cytori Therapeutics. You can read more about this process and its potential in our article on Stem Cells and Cosmetic Surgery.

These advances, however, do not ensure that autologous fat transfer is completely effective, safe, or risk free. For those who worry about cancer related complications that may arise from fat grafting breast augmentation, the systemic review we mentioned above, which was published in the Aesthetic Plastic Surgery in 2011 October has this to say:

“To our knowledge, no controlled human studies have addressed whether autologous fat grafts cause or accelerate breast cancer in humans or not. One study following patients for 10 years who underwent fat grafting for contour irregularities after lumpectomy for breast cancer did not find increased recurrence.” [4]

What about concerns regarding cancer?

When asked about patients concerns about breast cancer, Dr. Del Vecchio said:

“While we have made some progress in proving the efficacy and safety of breast augmentation with fat grafting, we have not yet reached the point where we can unequivocally demonstrate the long-term cancer risk. We don’t yet know.

From what we know, there does not appear to be any short-term increase in breast cancer incidence among patients receiving fat transfer to the breasts. But, this group will need to be followed over a lifetime before we know definitely that the risk of breast cancer in this group is different to the risk of breast cancer in the general population.

We are right now in the same situation pioneers of breast augmentation with implants faced in the 1960s; when patients asked if implants caused cancer. Two generations later, that question which appeared unanswerable at the time is generally considered a nonissue. Of course, I’d like to say that my comments exclude the recent findings of an association between textured silicone implants and anaplastic non-Hodgkin’s lymphpoma.

To conclude this discussion, I would also like to state that breast fat grafting and breast implants should not be considered as mutually exclusive either or options for someone needing breast augmentation. Both can be used together for good effect.

Yes, it is true that implant manufacturers have looked at it that way; as if fat grafting is cannibalising their implant segment. And many surgeons, with rare exception, are experts in either one procedure or the other. This too adds to the friction. In my opinion it does not have to be this way. From an industry point of view, fat grafting for breast augmentation is going to help the whole breast augmentation field to move forward; and open it up to new patients.

And once patients have a positive experience, they are more likely to experiment, opening up other opportunities for implants as well.

So my take is that fat grafting with breast augmentation is going forward full steam, but we still have some way to go. I am very positive about future prospects.”

Note to our readers

Just like with any other procedure, those who opt for breast augmentation with their own fat should do their homework, know what they are getting in terms of expected outcomes as well as potential risks and complications and make informed decisions. Selecting a qualified surgeon who has expertise and experience in the procedure will go a long way towards assuring a successful outcome.

You may find the following articles useful:

• Stem Cells and Cosmetic Surgery
• Do Your Home Work
• Is Cosmetic Surgery for You?
• Breast Augmentation
• Breast Reconstruction