Breast augmentation with fresh-frozen homologous fat grafts

The science behind autologous fat grafting

INTRODUCTION

Adipose grafting has undergone significant changes over time. Many different techniques have been followed by trying to improve the quality of the lipoaspirate and the survival of the fat graft after implantation.

MATERIAL AND METHODS

The purpose of this review is to analyse the historical evolution of the surgical harvesting and implant technique, describing the changes that have brought significant improvements, revolutionizing the aesthetic and functional results obtainable.

RESULTS

A standard fat grafting technique is commonly performed in three stages: harvesting of adipose tissue from a suitable donor site; processing of the lipoaspirate to eliminate cellular debris, acellular oil and excess of infiltrated solution, reinjection of the purified adipose tissue. The most widely used surgical technique was described by Coleman. He modified and corrected the methods and results of his predecessors and proposed an atraumatic protocol for the treatment of adipose tissue.He reported that the key to successful fat grafting lies in the technique. In addition, he noticed that adipose tissue was not only a good filler, but improved the quality of the skin. In fact, fat grafts demonstrated to have not only dermal filler properties but also regenerative potential owing to the presence of stem cells in fat tissue.

CONCLUSION

Adipose tissue, actually, is the closest to the ideal filler because it is readily available; easily obtainable, with low donor-site morbidity; repeatable; inexpensive; versatile; and biocompatible. There is an abundance of literature supporting the efficacy of fat grafting in both aesthetic and reconstructive cases. Recent studies have shown the utility of adipose-derived stem cells in the improvement of wound healing, describing their ability to regenerate soft tissues and their remodelling capacity provided by their unique cytokine and growth factor profiles.Despite ongoing concerns about survival and longevity of fat grafts after implantation and unpredictability of long-term outcome, fat has been successfully used as a filler in many differ clinic situation.

Long-term follow-up of cadaveric breast augmentation: what can we learn?

Breast augmentation with cadaveric fat graft has long been available to patients in Eastern European countries, primarily in the Soviet Union and Eastern Germany. Most such procedures were performed from the 1970s to the 1990s. Although only a few case reports have been published, all of which involved complications that appeared several years after the procedure, it appears that, surprisingly, this nonvascularized and incompatible immunologic tissue is relatively well tolerated. We present the case of a 45-year-old Russian woman who underwent breast explantation, due to breast hardness and pain, 15 years after breast augmentation with cadaveric fat grafting. Through genetic studies, we confirmed that the host and the graft were HLA incompatible. Moreover, results of analyses excluded the possibility of an acute or chronic immunologic rejection by the host. We suppose that the early complications that often occur in such cases might result from a nonspecific, inflammatory reaction induced by acute tissue ischemia and necrosis, and the late local complications that occur years later may relate more to chronic inflammation, due to nonvascularized tissue, than to immunologic rejection. Therefore, we propose that different mechanisms may explain how this allogenic fat tissue could have been tolerated by the patient's immune system. We particularly underline the immunomodulatory effect of mesenchymal stem cells, which are abundant in adipose tissues. This characteristic of fat tissue should be investigated further to assess its potential in treating autoimmune diseases or reducing the likelihood of allograft rejections.

A clinical scalable cryopreservation method of adipose tissue for reconstructive surgery assessed by stromal vascular fraction and mice studies

BACKGROUND

Adipose tissue is widely used in plastic surgery. The main obstacle is that it can be used only immediately after liposuction, while reconstruction often requires several procedures to achieve optimal results. This study aimed to develop a cryopreservation protocol directly applicable to clinical situations, allowing repetitive procedures without multiple tissue harvests.

METHODS

The authors first tested scalable bags suitable for therapeutic uses. All subsequent experiments were performed in those bags. The authors evaluated in vitro, on the basis of cell viability, cell number, phenotype, and stromal cell proliferation, the efficacy of six cryopreservation media composed of an external cryoprotectant (human albumin or hydroxylethyl starch) with or without an internal cryoprotectant (dimethyl sulfoxide). Two storage temperatures (-196°C and -80°C) were tested in vitro and in vivo (subcutaneous graft in 30 nude mice) with the selected medium.

RESULTS

The combination of 5% dimethyl sulfoxide and 95% hydroxylethyl yielded in vitro results that were good and the most consistent. With this cryoprotective solution, the authors observed no significant difference in vitro for a storage period of 7 days. When the storage was extended to 1 month, the cell viability was decreased by 10 percent for both storage temperatures. The in vivo experiments assessed the superiority of cryopreservation at -80°C with less graft resorption (60 percent and 70 percent, respectively, for -80°C and -196°C) and less fibrosis.

CONCLUSION

The study's protocol with a chemically defined cryoprotective solution, specific scalable bags constrained in an aluminum holder, and a storage temperature of -80°C is promising for long-term adipose tissue cryopreservation.

Current applications and safety of autologous fat grafts: a report of the ASPS fat graft task force

TASK FORCE STATEMENT: In 2007, the American Society of Plastic Surgeons formed a task force to conduct an assessment regarding the safety and efficacy of autologous fat grafting, specifically to the breast, and to make recommendations for future research. The task force formulated specific issues regarding fat grafting and then compiled them to focus on five broad-based questions: 1. What are the current and potential applications of fat grafting (specifically breast indications, and if data are available, other cosmetic and reconstructive applications)? 2. What risks and complications are associated with fat grafting? 3. How does technique affect outcomes, including safety and efficacy, of fat grafting? 4. What risk factors need to be considered for patient selection at this level of invasiveness? 5. What advancements in bench research/molecular biology potentially impact current or future methods of fat grafting? To answer these questions, the task force reviewed the scientific literature, critically appraised the information available, and developed evidence-based practice recommendations. Although the primary issue of interest was fat grafting to the breast, other aspects of fat grafting were evaluated.

[Fat tissue transplant: restoration of the mammary volume after conservative treatment of breast cancers, clinical and radiological considerations]

The aim of this study is to evaluate fat tissue graft as a treatment of sequelae of breast cancer conservative surgery.

MEANS AND METHODS

This prospective study during a nine-month period concerned 15 patients with breast cancer conservative treatment sequelae. Fat tissue has been injected at the site where the tumorectomie and subsequent radiotherapy had been performed. A mammographic and photographic checkup along with the patients' subjective evaluation were done before the operation and after the operation with a one-month, three-month, and nine-month follow-up. An objective analysis of the results was done by a panel from the pictures of the ninth month's follow-up. Preoperative and postoperative mammary volumes were calculated by a CT scan using a 3D program.

RESULTS

Mean fat tissue injected was 63.3cc. Mean patients' satisfaction grade was 8.1/10 at one month and 6.7/10 at nine months. The estimation of the resorption at nine months was 52.6% according to the patients while announced at 47.5% with the CT scan. Eighty percent of patients estimated the operation as "light" and 60% would be ready to have another injection. Skin tissue quality was enhanced and only one infection has been stated. Two-thirds of postoperative mammographies are still ACR 2 and one-third of the patients have had cytosteatonecrosis.

CONCLUSION

This fat tissue graft technique on irradiated skin for the correction of tumorectomy sequelae brings a simple and efficient solution, which is radiologically reliable and satisfying for the patients.

Cryopreservation of human adipose tissues

Scientific studies on cryopreservation of adipose tissues have seldom been performed. The purpose of our present study is conducted both in vitro and in vivo to develop a novel cryopreservation method that can be used successfully for long-term preservation of human adipose tissues for possible future clinical application. In this study, samples of adipose aspirates were obtained from 36 adult white female patients after liposuction and collected from the middle layer after centrifugation. In the in vitro study, suitable cryoprotectant agents (CPAs) and their concentrations and possible combinations were selected from our preliminary experiment. A combination of dimethyl sulfoxide (Me(2)SO) and trehalose as CPA with the optimal concentration (0.5M Me(2)SO and 0.2M trehalose) was chosen and then used throughout the study. In addition, maximal recovery of adipose tissues was achieved after cryopreservation using slow cooling without seeding (1-2 degrees C/min to -30 degrees C, followed by plunging to -196 degrees C for storage) and fast warming (in 40 degrees C water bath, averaging 35 degrees C/min). Fresh adipose aspirates (Group 1), cryopreserved adipose aspirates without CPAs (Group 2), or cryopreserved adipose aspirates with CPAs (Group 3) were evaluated by integrated adipocyte counts and histology. In the in vivo study, fresh adipose aspirates (Group 1), cryopreserved adipose aspirates without CPAs (Group 2), or cryopreserved adipose aspirates with CPAs (Group 3) were injected into a nude mouse. The retained adipose aspirates (fat grafts) were harvested in each animal at 4 months and their weight, volume, and histology was assessed. In the in vitro study, significantly higher integrated viable adipocyte count (2.06+/-0.54 x 10(6)mL(-1) vs. 1.07+/-0.41 x 10(6)mL(-1), p<0.0011) of adipose aspirates was found in Group 3 compared with Group 2. Group 3 had only a marginally lower integrated viable adipocyte count compared with Group 1 (2.06+/-0.54 x 10(6)mL(-1) vs. 2.57+/-0.56 x 10(6)mL(-1), p=0.083). Histologically, more tissue shrinkage was evident in Group 2 compared with Group 3. In the in vivo study, various degrees of absorption of injected fat grafts were seen in all 3 groups. However, Group 3 had significantly more retained weight and volume of the injected fat grafts than Group 2 (both p<0.0001) but had significantly less retained weight and volume than Group 3 (weight, p=0.009178; volume, p=0.007836). Histologically, a large amount of tissue fibrosis was seen in Group 2, and reasonably well maintained fatty tissue with only a small amount of tissue fibrosis was seen in Group 3. The results from the present in vitro and in vivo studies, for the first time, demonstrate that our preferred cryopreservation method, the combination of 0.5M Me(2)SO and 0.2M trehalose as CPA in addition to the controlled slow cooling and fast rewarming protocol, appears to provide the maximum recovered results in cryopreservation of human adipose tissues and may become a real option after further refinements for cryopreservation of human adipose aspirates in a clinical setting.

Historique de l’utilisation du tissu adipeux comme produit de comblement en chirurgie plastique

Use of adipose tissue transfer in plastic and reconstructive surgery is not new, and has been the subject of numerous studies. Transfer of autologous adipose tissue was reported for the first time at the end of the 19th century. Ideas and techniques have greatly changed during the last century. Adipocyte transfer has attracted renewed interest in recent years, due in particular to the development of Lipostructure by Coleman, who introduced a procedure based on strict methodology and the use of specific material. The history of adipose tissue transfer is retraced through the works of various authors and briefly recounted by highlighting the major landmarks of its advance. The evolution of ideas and techniques can be divided into three periods. The period before the introduction of lipoaspiration was termed "open surgery", when adipose tissue was harvested by surgical excision. The next period is that following the discovery of lipoaspiration, called the "unrefined" period, during which adipose tissue was obtained by aspiration and reinjected without preparation. During the third period, following the works of Coleman, the adipose tissue now undergoes non-traumatic refinement before grafting; this period is called "non-traumatic refined". Various studies have shown that this technique causes little damage to the cells and have demonstrated survival of the tissue transferred. Discovery of the developmental capacities of the various lineages from a mesodermal stem cell, and in vitro culture of these cells, opens up new research perspectives and clinical applications. From this precursor cell, adipocytes, osteoblasts, chondrocytes, myocytes and neurone-like cells can be developed. The future of autologous reconstruction appears promising.

Sonographic findings in complications of cosmetic breast augmentation with autologous fat obtained by liposuction

A 37-year-old woman presented with breast pain after breast augmentation utilizing autologous fat obtained by liposuction. Mammography and sonography demonstrated fat necrosis in the right breast and a solid inflammatory mass in the left breast. The diagnoses were confirmed by biopsy.