Fat injection breast augmentation (FIBA) has been recently given a cautious note of approval by a task force of the American Society of Plastic Surgeons. Fat injections has gained widedpread use over the past decade for facial applications, including adding volume to sunken or depressed areas of the face and plumping up the lips. While the stability of the results has been quite variable, the use of a natural filling technique that could pose no foreign-body problems certainly has patient appeal and continues to drive up its usage.
Fat injections into the breast has always been viewed as taboo and even bordering on malpractice in historic plastic surgery circles. However, the science and techniques of fat grafting have improved and its use in the breast has gained acceptance as a reconstructive method for lumpectomy defects from cancer resections. That brings it one step closer to the breast augmentation patient.
Injecting fat into the breast for cosmetic enhancement, however, is quite different from its use in lumpectomy defects. It differs by the fact that two normal breasts are involved, the amount of fat graft material needed is larger, and the tolerance for irregularities or lumps is much lower. The aesthetic target that you are aiming for in the breast augmentation patient is much higher. But for those women who reservations about breast implants and who have the right breast tissue characteristics and goals, fat grafting may be an option.
Fat injection breast augmentation (FIBA) is in its infancy and not enough cases have been done that an absolute set of candidate criteria have been established. But the patient’s aesthetic goals and the quality of their skin and native breast tissue would seem to be very important. A modest increase in breast or cup size can be achieved, usually in the one-half to three-quarter cup range. It is not realistic to expect a cup or two cup increase to be obtainable. If that is your goal, go with an implant as it is more predictable and stable. Loose floppy skin with little breast tissue is the wrong type of fat recipient site. For FBA to be successful, there must be some breast tissue into which it can be injected. Good quality (non-stretched out) breast skin with no to minimal sagging is most ideal as it signifies a good vascular bed and can best show a modest volume increase.
While the dual benefits of FBA are often touted (fat removal from undesired areas and breast size increase), one must keep in mind that one of those benefits is not guaranteed. While fat harvesting and purification techniques have improved, fat injection survival is still variable and not completely predictable.
While many factors are involved (surgeon’s experience, site of fat harvest, how it is processed and injected) that influence the take of the injected fat, survival rates can be as low as 10% to near 90% of the transferred fat. It behooves one, therefore, to optimize the latest in fat transfer technology.
In my Indianapolis plastic surgery practice, I currently use centrifugation for fat isolation and PRP (platelet-rich plasma) as a stimulatory additive to the fat. Current scientific studies and clinical case reports support that both have benefits on enhancing fat graft survival so it makes sense to me to use both. As devices become available for stem cell isolation, this may replace centrifuging the fat or provide a cellular pellet (stem cells) to mix with the fat also. This may seem a bit of an alchemy approach (and it is) but not enough research studies have been done to demonstrate what one set of fat mixture techniques is most ideal.
The downside of FIBA, besides unstable or uneven breast volumes, is the potential for fat cysts or liquefaction due to necrosis. This may appear months later as a small swollen area or a small fluid-filled sac to the touch. Fat necrosis may also occur deep below the skin and may only ever appear on a mammogram. The exact incidence of these problems are unknown but, like capsular contracture with breast implants, it is always a possibility. (although this would occur in the first few months and not years later)
As of this writing, FIBA should be only considered for those patients who simply cannot consider having an implant and are prepared to take some risks with a novel medical procedure. It should not be viewed as a casual choice based the two operations that are not similarly effective..
Dr. Barry Eppley
Indianapolis, Indiana