Breast augmentation with autologous tissues: Procedures and Imaging complications

Transcription

1 Breast augmentation with autologous tissues: Procedures and Imaging complications Poster No.: C-1188 Congress: ECR 2012 Type: Educational Exhibit Authors: E. Shim, B. K. Seo, S. E. Song, E.-S. Yoon, K. R. Cho, O H. Woo, S. H. Lee ; Ansan-si, Gyeonggi-do/KR, Ansan/KR, 3 Seoul/KR Keywords: Inflammation, Infection, Grafts, Complications, Ultrasound, MR, Mammography, Breast DOI: /ecr2012/C-1188 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 36

2 Learning objectives Comprehend the background, past and current state of breast augmentation with autologous tissue. Illustrates the procedures and imaging complications of breast. Background Introduction The use of autologous tissue transfer is an alternative method of breast augmentation that uses no foreign implant materials. The benefits of this method are removal of unwanted fat at unwanted body part, no risk of implant rupture, and good feeling like real breast tissue. History of breast augmentation Breast augmentation has been performed for cosmetic purposes and for the filling of defects from breast resection for breast cancer. In 1800~1950s, various foreign materials used for breast augmentation, as a result, granulomatous and inflammatory reaction to foreign body was occured with disfiguring and painful breast!!! (Figure 1) Page 2 of 36

3 Fig. 1: Various foreign materials for use of breast augmentations in 1800~1950s. Figure 1. In 1800~1950s: various foreign materials for use of breast augmentation. Add to bad morphology and inflammation, they also caused ; Delayed detection of breast cancer by obscuring part of the breast during mammography. Compromise of cosmetic result related with scar formation around the implant capsule. Thus alternate implant filling material and other methods of breast augmentation were neccesarily sought. In 1985, Czerny performs first reported successful human mammary reconstruction. He transplanted a lipoma from her back to treat a mastectomy defect in actress. Bircoll and Novack described a procedure for breast augmentation and symmetry with autologous fat injection. The fat for transfer is obtained from the donor site by liposuction. Imaging findings OR Procedure details Procedure: Fat injection and Flap surgery Fat injection Page 3 of 36

4 Harvesting of adipose tissue. Liposuction at donor-site considering individual characteristics. Fig. 2 on page 28) Preparation of obtained adipose tissue. - Centrifuge () or vibrator - For viability of graft: Mixed with Vascular Endothelial Growth Factor(VEGF), Incubated in Platelet-Rich Plasma(PRP), Use of Cell-Assisted Lipotransfer (Fig. 4 on page 30) Injection to the breast. Transfer the contents to a smaller syringe, 1 cc Luer-Lok syringe and inject the obtained autologous fatty tissue to the breast. With multiple passes, injecting only a small amount with each pass, 0.2cc/1 aqliquot for minimizing resoprtion of grafted fat!! (Fig. 5 on page 30) Where is it injected? The best injection site. To minimize reabsorption of grafted fat, well vascularized plane is better. Although intraglandular layer has abundant blood supply, it is likely to avoid the parenchymal injection.(due to potential of breast parenchymal disease?) => No evidence of the best injection site: Variable injection site are used (subcutaneous layer, pectoralis/pre-and retropectoral space and retromammary space..). Flap surgery Flap surgery transfer skin, subcutaneous fat, muscle with supplying vessels and innervating nerves to a site of breast defect..type -Transverse rectus abdominis myocutaneous flap (TRAM flap) -Deep inferior epigastric perforator flap (DIEP flap) -Latissimus dorsi myocutanous flap (LD flap) -Gluteal flap. Method -TRAM flap: Partial or no sparing of rectus abdominis muscle Page 4 of 36

5 Fig. 6: TRAM flap References: JPRAS 2006;59: Deep inferior epigastric perforator flap (DIEP flap): Preservation of entire rectus abdonimis. Page 5 of 36

6 Fig. 7: DEIP flap References: JPRAS 2006;59: Latissimus dorsi myocutanous flap (LD flap): Fig. 8: LD flap References: Clin Plastic Surg 2007;34:75-82 Page 6 of 36

7 Fig. 9: LD flap References: Clin Plastic Surg 2007;34:75-82 Fig. 10: LD flap References: Clin Plastic Surg 2007;34:75-82 Page 7 of 36

8 Fig. 11: LD flap. References: Clin Plastic Surg 2007;34:75-82 Fig. 12: LD flap References: Clin Plastic Surg 2007;34:75-82.Flap selection -TRAM (m/c) is used in large volume (>1000cc) breast reconstruction. Page 8 of 36

9 -DIEP is used in more little than 1000cc of breast volume and in non-smoker. -LD is used in Obesity, Diabetes Mellitus. Complication of autologous augmentation of breast.benign complication; infection It can be occured in conditions of all breast operation as well as autologous fat injection. After autologous fat injection, infection has been reported within range of o.6~0.7%..benign complication; fat necrosis The most common benign finding on mammograms of reconstructed breasts in 1~20% after autologous fat injection. It may occur due to mechanical trauma caused by the blunt cannula used for injection. -On mammography: from oil cyst to irregular spiculated density, focal dense mass -On US: oval/lobular/irregular shaped, irregular/ill-defined marginated, hypo/hyper/complex echoic mass. Sometimes, similar to simple cyst, with echogenic internal bands, debris or mural nodule. -On MRI: According to the inflammatory reaction, the amount of visible liquefied fat, the degree of fibrosis at the time of study. Page 9 of 36

10 Fig. 14: Degree of fibrosis to the inflammatory reaction, the amount of visible liquefied fat on T1WI of MR in fat necrosis. -The radiologic findings and inflammatory process of fat necrosis. Fig. 15: The association between radiologic findings and inflammatory process..benign complication;calcification in fat necrosis. Page 10 of 36

11 According to Carvajal et al., in 2008, microcalcification, radiolucent oil cyst +microcalcification and coarse calcifications can be seen in fat necrosis. The Morphology of microcalcifications include round, spherical, puntate, dystrophic and clustered shapes. Fig. 16 on page 33 These micfocalcifications can mimick malignant calcification of breast cancer..malignant complication; Detection of breast cancer The development of fat necrosis leading to liponecrotic cysts and microcalcifications that could possibly interfere with breast cancer screening. In Illouz and Sterodimans's series, 670 patient underwent mammography 6 months and 1 year after grafting; No BI-RADS category 4 or 5. literature of other authors reported that microcalcifications by fat necrosis were evaluated to BI-RADS category 3 or less. But these studies are not controlled nor randomized. In patient with a family history of breast cancer, autologous fat injection is likely to be avoided..malignant complication; Tumorigenesis..? Several literatures suggested that mature adipocy-tes and adipocyte-derived stem cells(asc) favored an increase in tumor growth, both in vitro and in vivo. Vascular endothelial growth factor(vegf), as a additives, is critical for promotion of breast cancer. In contrast, intravenous injection of human ASC has been shown to inhibit tumor growth and lung metastasis in a mouse model with human breast cancer. In 2009, the American Society of Plastic Surgeons (ASPS) Fat Graft Task Force stated, "Regarding fat grafting to the breast, there are no reports suggesting an increased risk of malignancy associated with fat grafting." Sample cases Case 1. Page 11 of 36

12 Fig. 17: Case 1. A-43-year-old-woman complaining Lt. palpable mass who had autologous fat injection in both breasts. Case 2. Page 12 of 36

13 Fig. 18: Case 2. A-39-year-old-woman with hardness of Rt. Inner breast who had autologous fat injection in both breasts 6 months ago. Page 13 of 36

14 Fig. 19: Case 2. A-39-year-old-woman with hardness of Rt. Inner breast who had autologous fat injection in both breasts 6 months ago; biopsy-confirmed fat necrosis. Case 3. Page 14 of 36

15 Fig. 20: CASe 3. A-46-year-old-woman with Rt. palpable mass after autologous fat injection in both breasts. Page 15 of 36

16 Fig. 21: Case 3. A-46-year-old-woman with Rt. palpable mass after autologous fat injection in both breasts. Case 4. Page 16 of 36

17 Fig. 22: Case 4. A-37-year-old-woman complaining Lt. palpable mass who had autologous fat injection in both breasts. Case 5. Page 17 of 36

18 Fig. 23: Case 5. A 36-year-old woman with no clinical symptom. Page 18 of 36

19 Fig. 24: Case 5. A 36-year-old woman with no clinical symptom. Case 6. Page 19 of 36

20 Fig. 25: Case 6. A 53-year-old woman with palpable masses after autologous fat transplantation. Page 20 of 36

21 Fig. 26: Case 6. A 53-year-old woman with palpable masses after autologous fat transplantation. Case 7. Page 21 of 36

22 Fig. 27: Case 7. A 23-year-old woman with a palpable mass in right breast after autologous fat transplan-tation. Page 22 of 36

23 Fig. 28: Case 7. A 23-year-old woman with a palpable mass in right breast after autologous fat transplan-tation. Case 8. Page 23 of 36

24 Fig. 29: Case 8. Normal imaging appearance in patient done left TRAM flap surgery. Page 24 of 36

25 Fig. 30: Case 8. Normal imaging appearance in patient done left TRAM flap surgery. Case 9. Page 25 of 36

26 Fig. 31: Case 9. Fat necrosis with calcification in patient operated to right TRAM flap surgery. Page 26 of 36

27 Fig. 32: Case 9. Fat necrosis with calcification in patient operated to right TRAM flap surgery. Page 27 of 36

28 Fig. 33: Case 9. Fat necrosis with calcification in patient operated to right TRAM flap surgery. Images for this section: Page 28 of 36

29 Fig. 2: Liposuction at donor-site considering individual characteristics. Page 29 of 36

30 Fig. 3: Preparation of obtained adipose tissue. Fig. 4: Cell-Assisted Lipotransfer Page 30 of 36

31 Fig. 5: Injection to the breast & breast anatomy; 0.2cc/1 aqliquot for minimizing resoprtion of grafted fat at appropriate site. Fig. 6: TRAM flap Page 31 of 36

32 Fig. 7: DEIP flap Page 32 of 36

33 Fig. 13: Algorithm for selection of Free TRAM or DIEP flap Page 33 of 36

34 Fig. 16: calcification in fat necrosis Page 34 of 36

35 Conclusion. Since the first successful case of transfer of lipoma to the mastectomy site in 1895, use of autologous tissue transfer have developed. It is an alternative method of breast augmentation that have many benefits replacing foreign body-implants.. There are autologous breast augmentation that autologous fat injection and flap surgery including Transverse Rectus Abdominis Myocutaneous flap (TRAM flap), Deep Inferior Epigastric Perforator flap (DIEP flap), Latissimus Dorsi myocutanous flap (LD flap).. On the process from liposuction, preparation, to fat injection into breast tissue, emphasis is minimal trauma to the adipose tissue and layering of small aliquots of aspirate to limit resoprtion of infected fat.. Complications include infection, fat necrosis, calcification etc.; when they are located in glandular tissue, a decision get confused, rarely mimicking malignancy on multi-modality imagings. There is no evidence of increased risk of malignancy associated with fat grafting.. Breast augmentation using autologous fat is very effective, satisfactory and minimally complicated procedure to patient, upto date. Personal Information References 1. Plast Reconstr Surg 1989;83: Ann Plast Surg 1987:18; Aesthetic Surgery J 30(4)2010; Aesthetic Surgery J 30(1)2010; JPRAS 2006;59: Clin Plastic Surg 2007;34: Plast. Reconstr. Surg 2002;110: Curr Probl Diagn Radiol 2004;33: Aesthetic Surg J 2008;28: Bircoll, M. Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 1987;79: Page 35 of 36

36 11. Bircoll M, Novack BH. Autologous fat transplantation employing liposuction techniques. Ann Plast Surg 1987;18: Matsudo PK and Toledo LS. Experience of injected fat grafting. Aesthetic Plast Surg 1988;12: ASPRS Ad-Hoc Committee on New Procedures. Report on autologous fat transplantations, September 30, Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg 2007;119: Pierrefeu-lagrange AC, Delay E, Guerin N, Chekaroua K, Delaporte T. Radiological evaluation of breasts reconstructed with lipomodeling (in French). Ann Chir Plast Esthet 2006;51: Wang Y, Qi K, Ma Y, et al. Fat particle injection autotransplantation: A 10-year review (in Chinese). Chin J Plast Surg 2002;18: Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the reconstructed breast. Plast Reconstr Surg 2005;116: Page 36 of 36