The latest kind of recycling has nothing to do with soda bottles. It entails liposuctioning fat from, say, thighs or buttocks and injecting it into breasts to augment them. After being condemned in the early '90s, this procedure is generating newfound excitement among the handful of doctors nationwide who offer it and patients keen to enlarge their breasts without resorting to implants.
Almost 20 years ago, the association now known as the American Society of Plastic Surgeons issued a warning to its member doctors to not inject suctioned fat into patients' breasts, for fear that mammograms would be misread. Since some injected fat dies and calcifies, the thinking was that radiologists would not be able to distinguish between those calcifications (or calcium deposits) and suspicious ones that may indicate breast cancer.
A second concern was that too little injected fat survived being transplanted, because techniques for harvesting, refining and placing fat were not advanced enough. Even today, the success of fat grafting to the breast, as the procedure is also known, depends on the physician.
But this year, the plastic surgery society reversed its former position. A report from its task force reviewed the limited research on fat grafting to the breast and concluded that it "can be considered a safe method of augmentation." On the issue of mammography, the report said fat grafting "could potentially interfere with breast cancer detection; however no evidence was found that strongly suggests this interference." Thus, the task force's statement turned a red stoplight into a yellow one, signaling to plastic surgeons: Proceed with caution.
And so some have. "The best way to create a normal breast is to use your body's own tissue," said Dr. Sydney Coleman, a Manhattan plastic surgeon who is an advocate of fat grafting. So much so that he no longer offers breast implants.
Sarah, a petite 34-year-old woman from Miami who asked that only her first name be used, considered implants, but said she didn't want her breasts to "look hard or fake or extremely unnatural." So she had Dr. Roger K. Khouri, a plastic and reconstructive surgeon in charge of the Miami Breast Center, take fat from her thighs and buttocks to fill out her chest.
"I love that it's just mine, my own fat," she said. "I didn't have to put anything foreign in my body."
At the October meeting of the American Society of Plastic Surgeons, Khouri presented a long-term study that suggested liposuctioned fat was now a "viable alternative to breast implants." It tracked 50 women, ages 17 to 63, for an average follow-up of 3.5 years. (For weeks, participants wore a cumbersome bra-like tissue expander at night that was created by Khouri to create a scaffolding for their fat.) The study, which Khouri plans to publish in a peer-reviewed journal, found that the procedure does not impede the reading of mammograms and that on average, 85 percent of transplanted fat survived to give patients natural-feeling larger breasts.
This kind of breast augmentation is a two-fer: Trim fat where you don't want it and put it where you do. Another advantage is not having to worry about an implant breaking or hardening.
But the disadvantages cannot be discounted. It's usually more expensive than implants, it takes a year to see how much fat survived, and breast volume can fluctuate with weight. Dr. Scott L. Spear, the chairman of the plastic surgery department at Georgetown University Hospital, has enlarged a patient's breasts only to have the patient undo his handiwork by losing weight. "They decide to run a marathon and their breasts go away," he said.
But a far worse scenario is that a doctor's technique is so wanting that much of the transplanted fat dies and complications ensue. "Anyone can take fat and inject it into the breast, and the patient will look good immediately afterwards," Khouri said, but a few months later, the fat injected by a doctor with sub-par skills may result in "oil cysts, masses, nodules and scarring."
To some, this kind of fat recycling seems simple. But Dr. Michael F. McGuire, the president of the American Society of Plastic Surgeons, cautioned: "How you take the fat, how you process it, how you inject it are all factors in how successful fat survival is going to be."
In some cases, radiologists can distinguish between innocuous and suspicious calcifications, said Dr. Sameer A. Patel, a plastic and reconstructive surgeon at Fox Chase Cancer Center in Philadelphia. But when they can't, biopsies may be done. So he fears that fat injections for breast enlargement could increase unnecessary biopsies.
Last month, new guidelines from the U.S. Preventive Services Task Force recommended that most women should start mammograms
at 50, instead of 40, to try to reduce the number of tests, including biopsies for false positives.
But a baseline mammogram for a woman considering breast augmentation (or reduction) is a must, said Dr. Emily F. Conant, a radiology professor and the chief of breast imaging at the University of Pennsylvania Medical Center.
In recent years, fat injections have been used to correct irregularities from reconstructive breast surgery after a mastectomy or a lumpectomy. Because much smaller volumes of fat are used, some plastic surgeons felt comfortable, for example, filling in a dent in the cleavage area.
But Dr. Stephen F. Sener, a professor of surgery at the Keck School of Medicine at the University of Southern California, wrote in an e-mail message: "I've seen enough injections of fat after mastectomies to tell you that fat necrosis is a real problem." It can result in a "palpable mass" that needs to be biopsied to establish malignancy or infection, wrote Sener, the former president of the American Cancer Society.
It's a pivotal time to set the record straight on fat grafting to the breast. Recently, television news segments have featured doctors touting "natural breast augmentation." In one segment available on YouTube.com, from an ABC station in Phoenix, a patient said she grew two cup sizes after injections. Most doctors injecting fat for breast augmentation say implants are a better choice for such an increase.
The pleased mother of three in the news clip said her breasts grew "overnight," which is misleading. Typically, doctors wait months to assess whether transplanted fat is there to stay. Others wait longer. "Unless you go a year, you can't say 'we succeeded,'" Spear said.
Yet, marketing for fat-enhanced breasts has ramped up. The Web site naturalaugmentation.com lists several doctors, mostly ob-gyns and family medicine physicians, not plastic surgeons, who offer coupons for "natural augmentation" and even something called "stem-cell breast augmentation."
A company called Cytori Therapeutics makes a machine used in Europe that concentrates the cells within fat tissue that aren't strictly fat cells, including stem cells. The company hopes that its Celution 800 system can "double the cells that act as fertilizer, so it's possible to achieve a more predictable graft," said Tom Baker, the director of investor relations.
But Cytori's machine hasn't been approved by the Food and Drug Administration. Nor has "concentrating" cells in fat been proved to make a difference in controlled studies, said Dr. Karol A. Gutowski, chairman of the plastic-surgery society's task force.
That hasn't stopped Dr. Todd Malan, a board-certified ob-gyn in Scottsdale, Ariz., who is the surgeon in the ABC news clip, from anointing himself the "First in U.S. to perform Stem Cell Enhanced Breast Augmentation!" on his Web site.
Coleman, who was part of the task force, said, "it's easy to kill fat," and worried that Johnny-come-latelies won't be meticulous. "Suddenly everyone is claiming to have 10 years of experience," said Coleman, who is a paid adviser to Cytori.
Coleman has that experience. In 1998, when augmenting breasts with fat was "unheard of," Linda Francipane, a hairdresser in Manhattan, had her modest chest filled out by him. "The best part is I'm in my 40s and I have these nice perky breasts," she said. "They look like teenager breasts."