Risk classification for fat grafting for breast augmentation

Fat grafting for breast augmentation is the hot topic in plastic surgery.  I went to a symposium two years ago.  As I have been saying, I think it is the way of the future.  I have not started doing it yet.  Why?  I have been gathering information and technique points to make sure when I start doing this surgery, I am as safe and well informed as I can be.

I found a table of risk classification published in the April 2011 Plastic and Reconstructive Surgery Journal.  It was in a discussion written by Dr. Del Vecchio out of Boston.  He was one of the speakers at my symposium.  I think this classification has a lot of merit.

Due to the risk of fat calcifying when it is transferred, you need to think about what that would mean.  If you are at a high risk for breast cancer or have already had breast cancer, your mammogram is a BIG deal.  You should not do fat transfer, as it could appear to be a cancer if you do get calcifications.  For you, an implant would be a better choice.

HIGH RISK:

• If you have a known risk of breast cancer (strong family history, BRCA gene)
• Lumpectomy defects.  This means you have had a breast cancer already



MODERATE RISK

• Breast augmentation for core volume projection.  In English, this means grafting a moderate to large amount of fat all over the breast to increase your breast size.  In his table, he thinks implants are still the “cancer safe alternative”, and the accepted standard.

For the rest of these, he feels that fat grafting is superior to the current method or offers a current unmet clinical need.

MODERATE RISK:

• Severe breast asymmetry (Means you are lopsided)
• Tubular or constricted breast  (These are natural variations in the shape of the breast, where the breast is tubular, too narrow, short in the lower pole, or has other issues.  These breasts usually need to be reshaped)
• Poland Syndrome (Where a congenital defect causes you to have poor to no formation of the breast and pectoral muscle on one side)



LOW RISK

• Revision of reconstruction border zone defect. (When you do a breast reconstruction with a TRAM or implant, sometimes there is a drop off or abrupt edge where you go from the reconstructed portion to the normal portion.  You can do fat grafting at this border to smooth the transition. You are low risk here because you are after mastectomy, so no breast tissue remains in the breast.)
• Severe deformities after explantation and tissue loss. (You have irregularities and deformities after removal of implant or loss of skin, breast tissue, muscle, etc.)
• Revision grafting over implants after reconstruction.  (This is where no breast remains, and this allows you to put more new healthy tissue than you can with allograft or dermis.)
• Mastectomy defects.  (This is after your general surgeon has removed all the breast tissue.  In this case, we assume all breast tissue is gone.  You usually do not monitor with mammogram, as all breast tissue is gone.  If calcifications were seen in this scenario, then you would not assume a breast cancer, you would assume it is fat calcification from the fat grafting.)

I like this table.  I think it is starting to give us an educated framework of how to use fat grafting safely.  The pivotal and most controversial group is that first time breast augmentation patient with no strong history of breast cancer.  Do we use implants in these patients? Do we do fat grafting?  This is the group of the 25 year olds who are size A cups and want a little something… The moms who breastfed three kids and were deflated to nothing.  This is my patient base.  In his table, he states that implants are still the “cancer safe accepted standard.”  What can we do to make fat grafting a safe acceptable standard?

More blogs to come.