Consumer summary Autologous fat transfer for breast augmentation (The report of the Review Group has been adapted for consumers by E.

Transcription

1 ASERNIP S Australian Safety and Efficacy Register of New Interventional Procedures Surgical Consumer summary Autologous fat transfer for breast augmentation (The report of the Review Group has been adapted for consumers by E. Ahern ) Introduction Autologous fat transfer for breast augmentation is a surgical technique that has been developed to increase the size of the female breast. ASERNIP-S has reviewed the available published evidence to compare the safety and effectiveness of this procedure with conventional techniques of breast enlargement using saline and silicone gel implants. What is the normal anatomy of the female breast? The female breast is made up of mammary glands, fibrous tissue connecting the glands to the muscles of the chest wall, and fatty tissue, which gives the breast its shape (see figure 1). During lactation, the glands secrete milk that is transported in ducts to the nipple. Figure 1: Anatomy of female breast 1

2 Conventional surgical techniques used to enlarge the female breast A breast implant is a silicone shell containing either silicone gel or saline (salt water solution). During surgery, the implant may be placed directly under the tissues of the breast or between layers of muscle on the chest wall (see figure 2). Figure 2: Implant placed under breast tissues or between layers of chest muscle What may go wrong with breast implants? Silicone, either from the shell of the implant or the silicone gel inside, has been associated with inflammation of breast tissue, leading to the production of scar tissue. This scar tissue forms a capsule around the implant and is known as encapsulation. Saline implants are most commonly used, but they are also prone to scar encapsulation due to reaction to the silicone shell that contains the saline. The appearance or feel of the breast can change over time, especially due to distortion from the scar contracture. Other complications may occur, such as infection of the implant. Implants do not last forever. In these cases, further operations may be required to remove or replace the implant. How does the new surgery compare with the conventional surgical techniques? Fat cells taken from elsewhere in a patient s own body are called autologous fat. To enlarge the breast, fat cells from, for example, the thigh, are sucked out of the body using 2

3 liposuction and injected into the breast (see figure 3). Only very small quantities are transplanted at a time because the fat cells need to develop their own blood supply or they will die. Figure 3: Autologous fat transfer There is not enough evidence to compare the safety and effectiveness of this procedure with the more conventional techniques of breast implantation using breast implants. The little evidence available is summarised below. In terms of safety, no deaths were reported in the research studies. Although breast implants seemed to be associated with a higher overall rate of complications than the newer procedure, the numbers of autologous fat transfer patients were too low for a true comparison to be made. The complications reported included the following: Autologous fat transfer Calcification of fat droplets is the most common complication (1.4 15% of cases). This may give false positives for breast cancer under mammography, leading to more biopsies. Infections may occur (up to 10.5% of cases). Large sacs of dead tissue (necrotic cysts) can form which must be removed by reoperation and a saline or other prosthetic implant may be needed to restore the original shape of the breast. 3

4 Saline implants Contraction of hard capsules formed around the implant (capsular contraction) is the most common complication (1% - 40% of cases). This can create a breast that is hard, distorted or painful. This condition is more likely to develop with implants that are made of smooth rather than textured material. Deflation, or a drop in size of the implant, occurs when saline leaks into the tissues of the body (0.5% - 38% of cases). Some evidence suggests that the more modern implants last longer. Low rates of infection and haematoma were recorded. Pain experienced by patients after the operation was reported in one study. Implants bulged through weaknesses in the breast capsule in rare cases. Implants may lead to problems in the mammography of the breast. Alternative methods such as magnetic resonance imaging have been helpful. Reoperations were required in some cases (up to 29% of cases). Cohesive silicone gel implants Low rates of capsule formation, haematoma, movement or drop of the implant, and fullness of the top of the implant were recorded. During mammography, silicone hid breast tissue in 25% and 41% of patients in two case series. Better results were achieved for implants placed between the muscle layers on the chest wall than those placed directly under breast tissue. Reoperations were required in up to 6% of patients. Effectiveness of the operations was measured in terms of breast enlargement and patient satisfaction: Autologous fat transfer: Only a small increase in breast size is theoretically possible using this technique (no more than one bra cup size). From 30 to 400ml of liposuctioned fat has been injected in stages into the female breast, sometimes over a period of months. If injected fat is reabsorbed by the tissues, however, it no longer acts to enlarge the breast. Rates of 4

5 fat reabsorption ranged in different case series from less than 20% after 1 year with breast enlargement maintained by fibrous tissue, to 100% reabsorption (and hence no increase in breast size) after 12 months. In this latter case the operation was found to be completely ineffective. Not enough evidence was available on patient satisfaction following this operation. Saline implants The amount of saline in an implant varies and can be used to produce small to large increases in breast size. Saline will only be reabsorbed if deflation occurs. Capsular contracture will affect the size and shape of the breast. Implants can wrinkle if the implant is too big for the overlying pocket of breast skin, or if the implant is not filled with enough saline. Skin wrinkling over a wrinkled implant is more likely to occur for saline implants with smooth rather than textured shells. Not enough evidence was available on patient satisfaction following this operation. What is the recommended procedure for treating the disease? There is too little data available to decide whether autologous fat transfer for enlargement of the breast is as safe or effective as the conventional techniques of saline and cohesive silicone gel implants; certainly larger increases in breast size could only be achieved with prosthetic implants. The masking of breast cancer after the newer procedure due to calcification of fat droplets is of major concern, but implants can also affect mammography by blocking breast tissue from imaging. It is also unclear if autologous fat transfer does what it sets out to do, namely enlarge the breast, as the fat droplets can be reabsorbed by the breast tissue and the small amount of published evidence is contradictory. For these reasons the Royal Australasian College of Surgeons could not endorse the collection of data within Australia for this procedure. Key words: breast augmentation, breast enhancement August

6 Important note The information provided is based on up-to-date research. However, it is not intended to replace the advice of your medical practitioner. Please ask your doctor if you have any further questions about the management of this condition. For further information about ASERNIP-S Contact Professor Guy Maddern, ASERNIP-S Surgical Director, PO Box 688, North Adelaide, SA 5006, ph. (08) , fax (08) , or visit the website ( If you would like to provide feedback on this consumer summary, please contact us at ASERNIP-S is a programme of the Royal Australasian College of Surgeons (RACS). 6

7 Glossary autologous: relating to the patient s own body calcification: calcium build-up in tissues deflation (of implant): a drop in size of the implant due to leakage of contents gland: a group of cells that secrete substances for use by other cells in the body haematoma: a bruise or collection of blood in a tissue lactation: secretion of milk from the glands of the female breast liposuction: fat cells from the body are sucked into a tube connected to a vacuum pump mammary gland: group of milk-secreting cells in the female breast necrotic cysts: large sacs of dead tissue prosthetic: artificial or man-made saline: salt water solution 7