Larissa Macko ENC 1102 Professor Leslie Wolcott March 14, 20131 My discussion revolves around a procedure performed

by plastic surgeons. This procedure, known as autologous fat grafting or lipofilling, is performed mostly on breast cancer patients who have had a mastectomy. There are also patients who are born with defects such as Poland syndrome, which is the underdevelopment of the chest muscle. This procedure can also be performed on regular healthy women. This process includes liposuctioning fat from either the abdomen or buttocks area, harvesting it in preparation to be injected and eventually sculpted back into the breast area creating a natural texture and shape of a breast desired by the patient. The articles included in this bibliography were selected because of its relevance to the lipofilling procedure. There are multiple articles including studies that discuss the procedure and techniques used. The authors based on their research and performance formed conclusions that are comparable. For example, it is mentioned by multiple authors that this procedure is simple and each study uses patients whove undergone this reconstructive process. Also, many of the patients selected were done so randomly or chosen specifically so they would not have a confounding variable to influence any results. And when compared to each other, the final conclusions do not vary too much about being a safe procedure. This procedure takes years of experience to master for consistent results. A couple articles describe and compare the procedure performed over a period of time by the same surgeon. This allows the reader to also see the difference between early year surgeons versus a surgeon who has been performing it for ten years or more. This bibliography is a clear presentation of what to expect throughout the fat grafting procedure, before and after.

Macko 2 L. Bonomo, et al. "Radiological Findings In Mammary Autologous Fat Injections: A MultiTechnique Evaluation." Clinical Radiology 68.1 (2013): 27-33. Academic Search Premier. Web. 28 Feb. 2013. In this article, Bonomo accredited to the Universit Cattolica del Sacro Cuore, Policlinico Universitario in Rome for the study of clinical radiology and plastic surgery. The purpose is to describe the radiological appearance of normal and pathological findings in lipofilling, fat- injections. Patients who had undergone lipofilling from January 2008 to December 2010 were enrolled and examined. Mammography, ultrasonography, and magnetic resonance imaging (MRI) were taken before the operation, and 6 and 12 months after the procedure. There were no complications. Normal findings due to lipofilling (oil cysts) were identified in 23 cases using ultrasound and in 16 using MRI. Liponecrosis, the most frequently observed complication, was detected in four cases using ultrasound and in eight by MRI. In one case mammography showed calcific fat necrosis. Necrosis is the premature death of cells in living. It is concluded that normal findings due to lipofilling are better identified by ultrasound, and pathological findings are best identified using MRI. Liponecrosis most frequently occurs when large amounts of fat are injected. In the authors' experience lipofilling does not interfere with breast cancer early diagnosis (Bonomo et al. 27). This is important to my research because it exemplifies how important it is to look at all aspects of research in my field of study. Catherine Bruant-Rodier, et al. "Evaluation Of Breast Lipofilling After Sequelae Of Conservative Treatment For Cancer." European Journal Of Plastic Surgery 35.3 (2012): 221-228. Academic Search Premier. Web. 14 Mar. 2013. Dr. Catherine Bruant-Rodier from the department of Plastic and Maxillo-facial Surgery, Hpitaux Universitaires de

Macko 3 Strasbourg in France raises two questions about fat transfer in the breast; the procedures efficiency in terms of volume and curve and the impact on both breast imaging and oncological evolution. Ten patients underwent lipostructure according to Colemans technique and their overall treatment satisfaction was studied. The patients fat

resorption is at maximum rate between three to nine months. They each also had a mammography before lipofilling and three years after. The mammography, ultrasonography, and RMI images also allowed 90% of the cases to distinguish postlipofilling images from radiological abnormality from breast cancer (Catherine BruantRodier, et al., 221). Steatonecrosis and oil cysts appeared in some patients. Long- term satisfaction remained constantly good amongst patients, 70% were satisfied with the total treatment after three years. Self- evaluations seemed reliable due to the positive correlation with the CT scans. Because the resorption stabilizes after nine months, according to patient self-evaluation and CT scans, this allows repeating lipostructure, which in turn gives greater satisfaction (Catherine Bruant-Rodier, et al., 227). Feedback from patients is helpful after the procedure for surgeons because it allows them to help satisfy the patient to the best of their ability while documenting the results. As a plastic surgeon, which I soon hope to become, it is their role to keep the patient content with whichever surgery is being performed and this article exhibits the consideration towards patients feedback as well as the physical results, which affect them. Especially in this case because its the treatment of sequelae of conservative breast cancer surgery, which isnt taken lightly.

Macko 4 E Delay, et al. "Radiographic Findings After Breast Augmentation By Autologous Fat Transfer." Plastic And Reconstructive Surgery 127.3 (n.d.): 1289-1299. Science Citation Index. Web. 14 Mar. 2013. The authors who are from the Department of Plastic and Reconstructive Surgery, University of LyonLon Brard Cancer Center; the Unit of Radiology, Jean Mermoz Private Hospital; private practice; and the Department of Plastic Surgery, Edouard Herriot Hospital, University of Lyon collectively organized a group of healthy women. They tried fat transfers to healthy breasts, meaning women with no history of breast disease, particularly breast cancer. The study was conducted at the cancer institute of Lyon, France with the review boards approval. The procedure was done by Coleman technique with minor variations. 76 women during 200-2008 had undergone lipomodeling. They collected the fat tissues, prepared it, and injected it. Mammograms were taken and analyzed strictly, before and after. This study demonstrated that lipomodeling doesnt seem to affect the radiographic follow-up of the patients. Breast density was mostly stable over time. Radiographic follow-up treated fat grafting to not be problematic and shouldnt be a hindrance to the procedure. This journal was significant to me because it expands beyond the horizon of the procedure. It allows for advances to open up for this procedure by approaching it from different aspects, such as performing on a healthy woman versus a pre-cancer diagnosed one. E Delay, et al. "The Oncologic Outcome And Immediate Surgical Complications Of Lipofilling In Breast Cancer Patients: A Multicenter Study-Milan-Paris-Lyon Experience Of 646 Lipofilling Procedures." Plastic And Reconstructive Surgery 128.2 (n.d.): 341-348.

Macko 5 Science Citation Index. Web. 14 Mar. 2013. Jean Yves Petit, M.D., Division of Plastic Surgery, European Institute of Oncology studied the outcome and complications of lipofilling along with three other institutions. They all compared their results amongst each other. They set up a multicenter study gathering information from the institutions with a large experience of breast cancer treatment and reconstruction (European Institute of Oncology, Milan, Italy; Paris Breast Center, Paris, France, and Leon Berard Centre, Lyon, France). The patients' data from each institution were collected and registered systematically on the same case record form. All patients' preoperative clinical and radiologic data were registered. The techniques of lipofilling procedures were recorded. The missing data were completed by telephone call and/or appointment. Patient age, date and indication for oncologic surgery, radiotherapy, tumor histopathology and staging, indication for lipofilling, type of anesthesia, donor sites of fat harvesting, volume of preparation and injection, complications, and clinical and radiologic follow-up data before and after lipofilling were registered. They used the same technique when performing lipofilling. They reviewed 646 procedures from 513 patients and observed only 18 complications. However, injection of fat into a previous tumor site may create a new environment for cancer cells and adjacent cells because of cell purification or by adding stimulus factors. A yearly follow up is conducted with a mammography and has so far led to the conclusion that this multicenter study confirms that lipofilling following breast cancer treatment leads to a very low rate of complications and does not affect the radiologic follow-up after breastconserving surgery.

Macko 6 This is important in my field of study because it demonstrates how precautions are taken for the best interest of the patient and procedure. Also, the combination of information from the three institutions leads to a conclusion, which shows how valuable information can be to others in the same field. NA Fine, et al. "Long-Term Outcomes Following Fat Grafting In Prosthetic Breast Reconstruction: A Comparative Analysis." Plastic And Reconstructive Surgery 130.5 (n.d.): 984-990. Science Citation Index. Web. 28 Feb. 2013. Dr. Neil A. Fine, from the Division of Plastic Surgery, Feinberg School of Medicine, Northwestern University, has conducted a study on long-term implications for fat-grafting patients. A total of 886 breast reconstruction patients, both fat-grafting and non-fat-grafting, were followed up 10 years after the procedure. Previous follow-ups are usually three and a half years later and they decided to follow up further than that. With evidence from other colleagues, longterm implications are similar. Dr. Fine has studied work by de Blacam et al.,12 Kanchwala et al.,13 and Losken et al.14 has looked at series of patients who underwent post reconstruction fat grafting (n = 49, 110, and 107 patients, respectively), finding that fat grafting had low complication rates and improved contour deformities. Unfortunately, despite their encouraging results, none of these studies reported on their associated oncologic outcomes. Meanwhile, Delay et al.6 reported a large series of patients who underwent fat injection (n = 734 following breast reconstruction), with highly satisfactory results and no increased risk of cancer recurrence on long-term follow-up (Fine et al., 987). The other studies help support his conclusion about fat grafting and the long-term effects. He noticed that there was a missing association affecting the result desired, the oncologic

Macko 7 outcomes. So with that support, from the first study mentioned, he found another study that would discuss the oncologic outcomes as well as using his. The patients were stratified according to their stage in breast cancer. Variables that could influence the outcome were evaluated such as age, body mass index, smoker or non- smoker, etc. This study is long-term statistical analysis based on multiple patients who have undergone fatgrafting and there outcomes years after. It was unclear determining the indicators of a safe procedure is or how it is determined to be a recommendation except for no reoccurrence of cancer or complications arising. Fine concludes, Autologous fat grafting remains an attractive, and flexible, tool for optimizing aesthetic outcomes during breast reconstruction, with an associated low risk of complications. He also says Continued research in a prospective manner, however, is needed to establish fat grafting as a safe and routine technique for revisional breast surgery. We encourage reconstructive breast surgeons to continue to utilize fat grafting with careful oncologic follow-up and to report their experience in the scientific literature when possible (Fine et al., 988). His recommendation is validated by his achievements and research study. It is important for me because when dealing with breast cancer patients in the future and their reconstructive surgery there is more of a risk and worry of cancer reappearance. Breast revision is not included in this study or its long- term effects. K Hirakawa, et al. "Complications After Autologous Fat Injection To The Breast." Plastic And Reconstructive Surgery 123.1 (n.d.): 360-370. Science Citation Index. Web. 14 Mar. 2013. Hirakawa and colleagues are from the Department of Plastic, Reconstructive, and Aesthetic Surgery and the NMR Laboratory, Nippon Medical School in Tokyo, Japan. He

Macko 8 is addressing the issue of complications after the autologous fat injection to the breast. The authors are concerned that untrained and untutored individuals, especially in Japan, are performing this procedure incorrectly. The authors report several cases of complications after this procedure (K Hirakawa, et al., 360). 12 patients who already received the procedure were reviewed. The results were as followed: All 12 patients (mean age, 39.3 years) had received fat injections to the breast for augmentation mammaplasty for cosmetic purposes. They presented with palpable indurations, three with pain, one with infection, one with abnormal breast discharge, and one with lymphadenopathy. Four cases had abnormalities on breast cancer screening. All patients underwent mammography, computed tomography, and magnetic resonance imaging to evaluate the injected fats (K Hirakawa, et al., 360). This is important because unskilled surgeons cause harm to patients if they do not possess the ability to perform the procedure correctly. A doctor in Japan who says this is not a simple procedure compared to the multiple doctors in Europe who view it as simple also wrote this. This article is a different perspective of how one view of the procedure process is taken compared to the rest. In the end, compared to all the other articles, all authors agree a well-trained and skilled surgeon should perform it. Illouz, YG, and A Sterodimas. "Autologous Fat Transplantation To The Breast: A Personal Technique With 25 Years Of Experience." Aesthetic Plastic Surgery 33.5 (n.d.): 706-715. Science Citation Index. Web. 14 Mar. 2013. Illouz, a plastic surgeon from Saint Louis hospital in France has had 25 years of experience performing the autologous fat transplant to the breast. This demonstrates how the more one surgeon performs, the more consistent he is with results. He had three different groups, which underwent the surgery.

Macko 9 Group I included patients with asymmetry after mastectomy and breast reconstruction; Group II consisted of patients with congenital breast asymmetry; and Group III included patients requesting bilateral breast augmentation. He started off with having the patient stand when marking them, had all his supplies prepared, the syringes filled with fat to inject. Each of the procedures was successful. The patients were satisfied with the symmetrical results of their breasts. Its most stable when the treatment is done in multiple sessions, each consisting of injection of small quantities of adipose tissue fat, which should also be harvested properly (Illouz YG, 708). This article is important because the amount of years of experience by one surgeon can lead to other surgeons to ask each other for advice about the best technique in certain cases. They can present their results from the past and can compare to the present, which in turn shows what was done different to help improve results. After so much practice the end results are consistent and in turn are satisfying for patients. In this field of study being precise is one of the main goals. BS Kim, et al. "Engineering Of Volume-Stable Adipose Tissues." Biomaterials 26.17 (n.d.): 3577-3585. Science Citation Index. Web. 14 Mar. 2013. Kim is a chemical engineer from Korea at the Hanyang University there. They have designed dome-shaped mechanical support structures fabricated by reinforcing poly(glycolic acid) fiber-based matrices with poly(L-lactic acid). This in turn allows the volume of the breast after being injected with fat in reconstructive surgery to last longer instead of decreasing sooner. Many synthetic and natural materials replace lost breast adipose tissue. Theyve been developed and tested, but the results were not satisfactory. Silicone may cause foreign body reactions and infection and collagen gel may shrink in vivo. Autologous adipose tissues have been

Macko 10 clinically used to regenerate adipose tissues in depressed regions in the breast. However, this therapy has problems of absorption and subsequent volume loss of transplanted adipose tissues. They created the support structure and left it in a vaccum to evaporate the chloroform. The fat of the patient was cleaned, the fiber gel was prepared to set the support structure, and then it was implanted. The support structures were analyzed with scanning electron microscopy. It creates room for adipose tissue regeneration (BS Kim, et al., 3578). The reconstruction of soft tissue is critical in patients suffering from soft-tissue defects due to cancer, trauma, or extensive deep burn. In particular, as surgical mastectomy or lumpectomy for treatment of breast cancer is being frequently performed, there is a significant need for breast reconstruction. This is important in my field of study because it demonstrates the interactions of two fields that can benefit one of them. An outside support system (done by chemical engineers) elongates the results desired by patients who undergo reconstructive surgery (performed by plastic surgeons). JY Petit, et al. "Safety Of Fat Grafting In Secondary Breast Reconstruction After Cancer." Journal Of Plastic Reconstructive And Aesthetic Surgery 64.4 (n.d.): 477-483. Science Citation Index. Web. 28 Feb. 2013. This journal article was created by a group of professionals from the European Institute of Oncology who are dedicated to the research of breast cancer. These oversea professionals are qualified to discuss the fat grafting process involved in plastic, reconstructive and aesthetics surgery. Fat grafting is the transfer of fat from one area of the body to another. 158 patients were selected to test the safety of fat grafting using Colemans technique by a single surgeon, 98 percent of which have had a personal history of breast cancer. It has been concluded that this is a good

Macko 11 procedure to use for repairing defects and better than a more extensive surgery such as myocutaneous flaps, which is made of tissue from skin and muscle. The procedure was performed under anesthesia, local or general, depending on patient conditions. They avoided putting fat as an excessive depot, which may result in liponecrosis and graft loss as well as judged the amount of fat needed to be grafted in each individual case, based on the tissue quality, shape and size of the defect (M. Rietjens et al. 478). This implies the best-fit safety precautions are taken when performing the surgery, which allows the results to include that under the best ability, this procedure is great. It is very simple and very reproducible, and, in most of the cases, can be performed under local anesthesia, as demonstrated in this present study. It is less invasive than any other surgical technique and we only had minor complications, which were very simple to manage, said when discussing the use of fat grafting. The procedure seems to be safe, complications were small and required at most oral antibiotics or dressings. This study has two major factors that influence the results, the surgical technique and tissue quality. This is important because it allows me to study the multiple factors that can effect procedures in plastic, reconstructive surgery, which I hope to one day be able to perform. Salgarello, M, G Visconti, and E Farallo. "Autologous Fat Graft In Radiated Tissue Prior To Alloplastic Reconstruction Of The Breast: Report Of Two Cases." Aesthetic Plastic Surgery 34.1 (n.d.): 5-10. Science Citation Index. Web. 14 Mar. 2013. Visconti, in the Dept of Plastic and Reconstructive Surgery in the University Hospital "A. Gemelli" in Rome, Italy recommends the autologous tissue reconstruction. However, not every patient is a candidate. Not all radiotherapies are comparable in dose, timing, and patient

Macko 12 tolerance. In this article they present the results of an alternative surgical management in oncoplastic breast surgery consisting of fat injections before implant placement. Six months after the last radiation treatment, a lumpectomy patient and a modified radical mastectomy patient each underwent two sessions of fat injection prior to implant placement, with a 3-month interval in between sessions. The implants were placed 3 months after the last fat injection. They followed up 12 months after the radial mastectomy case and 18 month for the lumpectomy case. There were no postoperative complications. It is concluded, The preliminary results show that fat injection in irradiated tissue prior to breast alloplastic reconstruction may reduce the radiation-related complications on implants. Benefits from fat grafting are in keeping with the theoretical basis of this surgery. Larger studies are needed to confirm our observations. This is important in my field of study because fat grafting uses your own fat that can adjust to your body better than an implant and wont cause as much complications because it is already naturally from your body. Comparing the two techniques allows me recognize and judge which treatment may be better under different circumstances of patients. PD Smith, et al. "Differentiating Fat Necrosis From Recurrent Malignancy In Fat-Grafted Breasts: An Imaging Classification System To Guide Management." Plastic And Reconstructive Surgery 130.4 (n.d.): 762-773. Science Citation Index. Web. 14 Mar. 2013. Paul D. Smiths, M.D., Division of Plastic Surgery, University of South Florida College of Medicine, objective was to develop standardized imaging classifications to distinguish less severe from severe lesions after fat grafting. 286 patients who had undergone fat grafting from 2006- 20011 were reviewed to identify patients with imaging

Macko 13 of clinically palpable masses. A radiologist who was blinded to the previous results reviewed all images independently. On ultrasound, 66 palpable masses were visualized in 37 patients. The problem he is trying to assist with is differentiating palpable lesions representing fat necrosis from palpable lesions representing recurrent cancer. From A-G the lesions the radiologist characterized lesions according to echo texture, location, size, vascularity, and margins in accord with published guidelines in the literature (PD Smith, et al., 762). The patients ultrasound images were observed and 66 lesions were visualized. The findings suggested that ultrasound analysis is reliable at differentiating palpable masses representing fat necrosis from palpable masses representing recurrent cancer after autologous fat grafting in breast reconstruction. Within my field and this subject matter, the ability to differentiate palpable masses, that may be harmful, through imaging progresses ensuring the safety of the fat grafting procedure. G Toussoun, et al. "Breast Fat Grafting (Lipomodelling) After Extended Latissimus Dorsi Flap Breast Reconstruction: A Preliminary Report Of 200 Consecutive Cases." Journal Of Plastic Reconstructive And Aesthetic Surgery 63.11 (n.d.): 1769-1777. Science Citation Index. Web. 14 Mar. 2013. Gilles Toussoun is from the Department of Plastic and Reconstructive surgery at the University of Lyon in France. The goal of the study was to describe the preliminary report of 200 consecutive patients undergoing latissimus dorsi flap and lipomodelling breast reconstruction without an implant. The first 200 consecutive patients treated with lipomodeling in the institution were reviewed. First, preoperative site markings were done to identify the harvest and graft sites. Then, harvesting fat graft from the abdominal area occurs to be injected into the breast. The

Macko 14 purpose of the procedure is to create a breast to be as natural as possible by texture and shape. Postoperative complications are rare and only three out of the 200 were reported. They were easily taken care of, two easily controlled infections at the site and one case of pneumothorax (collected gas/air between lings and chest), which requires a simple drainage. It is concluded that this procedure is simple, safe, and reproducible making it available for use in many indications of breast reconstructive and plastic surgery (G Toussoun, et al., 1776) This procedure has been performed since 1999 and is considered to be the most considerable advances in breast reconstructive surgery since then. In my field of study this article is important because the reports influence whether or not this procedure should be used. Out of 200 patients only three had affects, which were minor. The use of a procedure is based off of other findings just like this.