Fat grafting to the breast – Will it affect mammograms?

A cover of: plastic surgery journal

Fat grafting, also known as fat transfers or fat injections, is a plastic surgery procedure which removes fat from unwanted areas of your body, carefully processes the fat, and then reinjects your own adipose fat tissue where more volume is desired. Fat injections can help rejuvenate your face, your buttocks, your hands, or your breasts. Fat injections are also being used in Breast reconstruction surgery. Fat grafting will restore volume to the breast and can be performed with or without an implant.

Lately we have seen some plastic surgery blogs expressing concern regarding how fat injections to the breast affect mammograms. We feel that both sides of the story are not being told, so we would like to address that here.

When we wrote about fat grafting to the breast back in April of 2009, the conclusion from the ASPS position paper indicated no evidence that fat injections interfere with breast cancer detection and that results of fat transfers remain highly dependent on a surgeon’s technique and expertise. See our previous blog post, Fat stem cell injections to the breast – Risky?, for more detail.

Two years later it’s still being debated. The Plastic and Reconstructive Surgery Journal, a journal of peer reviewed studies from the plastic surgery community, recently published several papers that come to different conclusions about whether fat injections to the breast can interfere with cancer screening.

Let’s explore these publications to review the various findings.

The Chinse study

A map of China.

April 2011, Plastic and reconstructive surgery

Clinical analyses of clustered microcalcifications after autologous fat Injection for Breast augmentation

The recently released paper, published in the April 2011 issue, put fat injections to the breast in a negative light. The study was conducted by Chinese plastic surgeons at Meitan General Hospital and Peking Union Medical College Hospital in Beijing, China. The Chinese study concluded that fat injections create issues with mammograms used to detect cancer in the breast. Based on these findings, the study recommended prohibiting all fat injections to the breast.

This study analyzed ‘digitized mammographic films’ from 48 patients who had received fat injections to the breast from July 1999 to December 2009.

X-ray: Calcification from fat necrosis.

The study focused on calcifications which occur after fat grafting is performed.

When a fat injection does not take well, the fat cells can die (fat necrosis), and take on the appearance of a calcification. The Chinese study concluded that mammograms cannot distinguish between calcifications formed from fat or calcifications that may be cancerous. The study’s abstract conclusion states “clustered microcalcifications found after autologous fat injection for breast augmentation, cannot be distinguished from malignancy.”

Even though all calcifications were biopsied to be non-malignant, the study also reached a grandiose conclusion that fat injections to the breast “should be prohibited.”

So–should fat injections to the breast be outlawed?

Or is there another side to the story? If so, what is it? The heart of the matter is whether radiologists can distinguish if calcifications seen on mammograms are due to dead fat cells, or from malignant cancer cells. First of all, not all fat grafting produces calcifications. If a fat graft takes well, there will be fewer dead fat cells, or fat necrosis, thus resulting in fewer or no calcifications. However, a poorly performed fat graft will likely have lots of dead fat cells, likely resulting in more calcifications.

Let’s look at other recent articles that were published on the topic of fat injections and mammograms, all within the last month.

The discussion article about the Chinese study

April 2011, Plastic and Reconstructive Surgery
Daniel DelVecchio, M.D.

The same April 2011 Plastic Surgery Journal issue included a ‘Discussion’ article about the Chinese study. If you had a hard copy of April’s journal, you would simply turn from the last page of the Chinese publication to read the ‘Discussion’ section that immediately follows written by Plastic Surgeon, Dr. Daniel DelVecchio. Dr. DelVecchio was an early adapter of fat grafting to the breast and has been published frequently in the Plastic Surgery literature.

Dr. DelVecchio brought up several excellent points as to why the Chinese publication conclusion was without merit. One point addressed concerned the issue of the resolution quality of the mammograms. What type of mammography did the Chinese use? The Chinese publications stated that they used ‘digitized mammographic films.’

screen film mammograms are inferior to direct digital mammograms

– Dan DelVecchio, MD

According to DelVecchio, this would imply that plain screen film mammograms were initially imaged, and later digitized. Per DelVecchio: “the quality of digitized screen film mammogram is only as good as the quality of the original mammogram, and it is common industry knowledge that screen film mammograms are inferior to direct digital mammograms.”

In other words – did the Chinese study simply digitize mammogram films with inferior resolution?

Dr. DelVecchio pointed to the work of other fat grafting pioneers, such as Dr. Emmanuel Delay, who have described the ability to distinguish between benign and malignant findings on post fat grafting mammograms. DelVecchio cited the radiologic literature which supported the general concept that calcifications and fat necrosis can be distinguished from the malignant signs of irregularly shaped, high-opacity microcalcifications when supplemental imaging modalities are considered.

Other notable points made by Dr. DelVecchio included the need for standardization of fat injection procedures in order to minimize fat necrosis, which result in calcifications. Deviation from ideal fat grafting techniques result in poor fat take because some of the fat dies. It is these dead fat cells that can result in calcifications. As standards emerge for the best fat grafting techniques, there will be less fat necrosis and calcifications to show up on mammograms as a result of fat injections to the breast.

In DelVecchio’s opinion, modern mammography techniques can distinguish between malignancy and benign fat deposits found on mammograms.

The French study

A map of France.

March 2011, Plastic and Reconstructive Surgery

Radiographic findings after Breast augmentation by autologous fat transfer

Exactly one month prior to the Chinese article publication, a group of French surgeons published an article in the March 2011 issue of Plastic Surgery Journal. The study compared mammograms pre and post operative mammograms on 20 patients who underwent fat grafting to the breast. The study’s goal was to determine whether the transfer of fat to the native breast hampers breast imaging.

Using guidelines stabled by the American College of Radiology classification, the study concluded that radiographic follow up of breast treated with fat grafting is not problematic and should not be a hindrance to the procedures. However, the study did recommend that techniques used for fat injection patients should become standardized, so that reproducibility could be insured.

Our summary

As more radiographers gain experience with fat grafting, we expect this mammogram issue to diminish, as happened with the case of breast implants and mammography.

Additionally, there is one important fact to remember–of all the thousands of fat grafts to the breast that have been done to present, there is yet to be a reported case of a cancer being missed on a mammogram because of a previous fat graft.

By Dr. Ricardo L. Rodriguez MD Board Certified Plastic Surgeon Cosmeticsurg Baltimore, Maryland Ricardo L. Rodriguez on American Society of Plastic Surgeons.

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13 thoughts on “Fat grafting to the breast – Will it affect mammograms?”

  • buttock injections says:

    I think the effects of surgery of directly depends upon surgeons who are doing surgeries......
  • Alex says:

    It's unfortunate that there is so much controversy around breast fat grafting. Unlike breast implants, the procedure uses one's own body fat and leaves no artificial substance in the body. The results are modest but more natural in feel and appearance than implants.
    • Dr. Ricardo L Rodriguez says:

      Alex: Hi I looked at your website. Is Dr. Kaplan board Certified in Plastic Surgery or is he a dermatologist?
  • Deucey says:

    Hi Dr. Rodriguez, Are you familiar with the suction-device-assisted technique used by Dr. Khouri in Florida (His site with examples here: http://www.miamibreastcenter.com/augmentation/fat-transfer-before-after-photos.html), and also by del Vecchio (site here: http://www.mdbeautycare.com/before_after/breast_aug_injection/patient1.html) who you mentioned in this post (He also wrote a recent paper on the technique here: http://journals.lww.com/plasreconsurg/pages/articleviewer.aspx?year=2011&issue=06000&article=00036&type=abstract)? The results looks pretty impressive. According to them (and the pictures appear to support the claim), they're able to give fat transfer augmentations comparable to implants, with no fat necrosis. Have you considered offering this procedure yourself at some point? Something tells me there'd be no shortage of women in the market for getting that and the BBL done at the same time :-)
    • Dr. Ricardo L Rodriguez says:

      Deucy: I think the device works, but there are disadvantages. The person has to wear the suction device for weeks prior to the surgery. Secondly, doing the procedure at the same time as the butt lift is difficult for two reasons: 1) Sometimes there is just not enough fat to do both things. 2) After a Butt lift you have to lay on your stomach to protect the grafts injected into the butt, but then you would be putting pressure on the grafts placed in the breast. In my opinion, immobilizing the breasts and controlling swelling can give as good results as the suction device, but there is no denying that Drs Khouri and Delvecchio do good work. I also differ from them as to how to process the fat and how to inject it. In the end what counts are results, and I respect their work, even if my methods are somewhat different. And that is good for patients!
  • Deb says:

    Do you use cytori pure graft for breast fat transfer procedures and what percentage of fat can be expected to survive? Also, are you familiar with cytori celution800 crs?
    • Dr. Ricardo L Rodriguez says:

      The Cytori machine is not FDA approved in the US. I am not about to use it until its FDA approved for the simple reason that if there is a problem I would be in a vulnerable position. There are other ways of separating stem cells from fat using collagenase enzyme. Typical yields are anywhere from 600,000 to 1,000,000 cells per cc of fat tissue. The percentage of fat graft survival is more dependent on surgeon technique than the machine used. It's like saying if you buy a really good tennis racket your game will improve. Look at a surgeon's results, not the tools he uses.
  • Sussie says:

    Hi Dr, Rodriguez I am thinking in Breast augmentation, but I am not sure to do it with implants, because in 10 or 15 years I have to replace them. In the other hand I was reading about fat grafting in the breast. What is better to chose fat or implants? With Fat is possible to achieve a 300 cc augmentation? Thanks
    • Dr. Ricardo L Rodriguez says:

      Susie: It is definitely possible to get large volume augmentations, but you have to be ready for an initial period of swelling and compressive dressings. Fat grafting is not the standard yet, mainly because of its cost. A breast augmentation with implants is cheaper. It is not true you have to have to replace them every 10-15 years. Many patients go a lifetime without problems. A certain percentage of patients do have to change them because of problems. It is hard to predict who will have problems, but it is helpful to go into it thinking that you may need a repeat procedure at least once. If you are interest, contact Kelly at kelly@cosmeticsurg.net, she'd love to help you!
  • Joseph Stevens says:

    Dear Dr. Rodriguez, I want to ask if you personally make all procedures and where I can find the prices of them? Thank you.
    • Dr. Ricardo L Rodriguez says:

      Joseph: Yes, I personally perform all my procedures from start to finish. As for prices, contact Kelly at kelly@cosmeticsurg.net, she'll be more than happy to help!
  • Dean Greg says:

    I'm looking to get a fat transfer to my breasts. My doctor says they can get me up 2 cup sizes ( I am about 5'4 107 lbs and 22 years old). They're going to be using UAL technique. I've been hearing so many different opinions and I just want to know the truth. I dont know what to do, I'm really stuck. I want larger breasts but if I can do it without implants, I'd be ecstatic. My biggest fear out of all of this is the results of the Liposuction (I don't want to end up like Tara Reid with all the dimples). Can someone advise me on this matter?
    • Dr. Ricardo L Rodriguez says:

      Dean: Whatever you do, don't use UAL to harvest fat for breast Augmentation. The ultrasonic waves kill the good fat cells and the stem cells that naturally reside in the fat. In general, I am against energy assisted liposuction, as it tends to damage too much of the tissue. I have seen many lawsuits over the deformities left behind by UAL and "Smart Lipo" Check out my blog video on the choice of liposuction technique, and why I prefer thin cannula liposuction, the least harmful and most predictable technique for liposuction.