Live from Boston: Fat grafting controversies !!

Yesterday, I attended the “Boston Breast Workshop – 2011”. This was a whole day of scientific presentations and panel discussions on the many controversies surrounding the uses of fat grafting for both reconstruction and cosmetic enhancement of the breast. Panelists included local experts Dr. Dan delVecchio and Dr. Jay Austen, as well as Dr. Roger Khouri, Kotaro Yoshimura, Syd Coleman and others of international repute – truly a group of heavy hitters.

It’s pretty clear that fat grafting can work, and can be done safely in selected patients. There seem to be two major methods that work: pre-expansion of the breast with the BRAVA system, or use of Cell-Assisted Lipotranfer (CAL). So far, it’s not yet clear which method is better – as there hasn’t been a head to head comparison study. (This is in the works.) Other methods have pretty much fallen by the wayside. It is important to state, though, there is still concern about breast cancer issues, particularlly in patients with a strong family cancer history or those who have had a lumpectomy for breast cancer.

Essentially, one can sub-divide the operation into three parts: harvesting, processing and reinjection.

1. Harvesting – can be done with syringe liposuction or with manual liposuction. Jay Austen presented data to suggest that regular liposuction suction did not adversely affect the quality of the fat cells. Khouri prefers a spring-loaded syringe technique. New information suggested that low-power VASER (an ultrasonic lipo machine) could be used, but wasn’t any better than standard manual lipo in terms of the cells harvested. Water-jet lipo seems to wash the important stem cells out of the fat…which theoretically would be a bad thing, since Yoshimura feels that these cells are key to the success of the procedure. Power-assisted liposuction is still being looked at, to see whether it harms the fat or not.

2. Processing: lots of debate here. Coleman favors a high speed (1280 g) centrifuge. Khouri thinks that his low-speed 15g machine is better. Cohen reported that the Puregraft 250 system, which doesn’t use a centrifuge at all, gives the least amount of free lipid in the specimen to be grafted (free lipid is bad).

3. Injection: most authors avoid the glandular parenchyma of the breast. Coleman likes to put quite a bit of fat into the pectoral muscle. Khouri favors subcutaneous injection. Yoshimura puts it both above and below the parenchyma, but not in the muscle, injecting slowly and methodically. Delvecchio stresses a rapid procedure, to reduce ischemia time for the fat.

New gadgets: Khouri showed off his “lipografter” system. Jac-cell showed off their lipo cannisters and re-injection equipment. Cytori showed their new Puregraft 800 filter system.

Lots of good stuff. I’m still evaluating and digesting the new material, and how it’s going to affect what I do. But, it looks like, for women that want to have this technique, that use of the BRAVA system to prepare the breast is mandatory. One bit of consensus: if the breast was not pre-expanded, you can’t expect to get more than 100 cc of fat to survive.

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