First attempts
The idea of using fat when working on the breast is not new. Czerny describes, during a communication at the German Congress of Surgery in 1895, the first clinical case of breast reconstruction by transferring a large lipoma into the breast to fill the hollow of a lumpectomy following the removal of a fibroadenoma. Other authors then performed reconstructions or breast augmentation by fascio-cutaneous composite grafts, dermo-adiposal grafts from the buttock, or subcutaneous pedicle flaps. Hollender in 1912 and Willi in 1926 have also described a technique of fat transfer, quite close to the one we use today (without however introducing the concept of fat “spaghetti”, and the concept of the “spaghetti box”), but this technique was gradually forgoten, probably as a result of infectious complications; the surgical conditions and surgical equipment of the beginning of the last century were obviously very far from our current conditions.
Following Illouz’s work on liposuction in the late 1970s, which led to an important development of the liposuction technique and its wide use around the world, it became tempting to use the fat from steatomeries (localized fat areas) to increase the volume of the breasts, Illouz actually using this method in the 80s for breast and other localizations. This fat transfer process was called lipofilling. Similarly, Fournier described his technique of breast augmentation by fat transfer, which was reserved for patients refusing prostheses, and who wanted only a moderate increase in the volume of their breasts; he specified that he did inject only in the retro-glandular space, and not in the breast itself. Many surgeons were skeptical about this technique because the principles of modern fat transfer were not yet well codified and there was often a formation of disturbing-looking fat necrosis areas that could disrupt breast monitoring and breast cancer screening; on the other hand breast imaging was not what it is today and any breast swelling was potentially a diagnostic difficulty; the fear was great that the fat necrosis areas disrupt the diagnosis of a possible breast cancer.
The debate
The big controversy about fat transfer in the breasts was triggered by Bircoll in 1984 when he presented in Bangkok, then to the California Society of Plastic Surgeons in 1985, the case of a breast augmentation by transfer of adipocytes obtained by liposuction. This was a 20-year-old woman who had received fat transfer for correction of dog bite sequelae, and asked for a moderate breast augmentation using the same technique. According to him, this technique was to be reserved for the patients wishing a moderate breast augmentation because of the supposed risk of fat necrosis in case of injection of large volume. He highlighted the advantages of this technique in a publication in February 1987 in the American Journal of Plastic and Reconstructive Surgery: simplicity, no scars, early resumption of activities, elimination of prostheses and therefore their complications, without counting the secondary benefit at the level of donor areas. In April 1987, he published the case of a patient who had benefited from bilateral fat transfer after unilateral reconstruction using TRAM method. These two articles immediately triggered many virulent reactions of the opposition. Critics pointed to the fact that fat injections into a native breast could lead to microcalcifications and cysts making it difficult to detect cancer. Although Bircoll answered, quite rightly, that the calcifications after fat transfer are different from those of a neoplasia by their location and their radiological appearance (and that breast reduction surgery is also a source of microcalcifications), the debate was launched unfavourably, and in 1987, the American Society of Plastic and Reconstructive Surgeons (ASPRS) ruled and declared: “the committee is unanimous in deploring the use of autologous fat injection in breast augmentation, much of the injected fat will not survive, and the known physiological response to necrosis of this tissue is scarring and calcification. As a result, detection of early breast carcinoma through xerography and mammography will become difficult and the presence of disease may go undiscovered.” These claims were made without reference or supported scientific work +++, but based on an opinion of the members of the ASPRS Committee (now ASPS, American Society of Plastic Surgeons, which has now modified these recommendations currently completely obsolete). Following this recommendation from the largest plastic surgery scientific society of the time, and despite the lack of further references, although it was recognized at the time that any breast surgery was a potential oil cyst provider and / or mammographic changes, fat transfers into the breasts had become a source of a powerful taboo that no one officially dared to give away. This ban of the American Society led to a halt to research and experimentation on this subject of major interest to patients.
Ironically and paradoxically, and to emphasize the subjectivity of positioning on this sensitive subject, in 1987 a retrospective study on mammographic changes after breast reduction, published in the same review, reported that calcifications were found in 50% of cases at 2 years, and the author insisted that it was possible in most cases to distinguish them from those found in cancer. Despite this very high incidence of radiological images, and the risk of possibly interfering with the detection of breast cancer, no discussion on the abandonment of breast reductions had of course taken place, moreover on the efficiency and safety of the breast reduction intervention.
The gradual lifting of the controversy
In the early 1990s, American surgeon Sydney Coleman took up the topic of fat transfer, and lipofilling, and became interested in the use of it at the face level, particularly in the context of facial rejuvenation surgery. He refined the lipofilling technique, developed a specific material and named his technique lipostructure. The significant effectiveness of these fat transfers at the level of the face, used according to the modern principles of preparation and atraumatic transfer following the work of Coleman, Carraway, and Guerrero-Santos, that we used in the 90’s in surgery aesthetic and facial repair, gave us the idea to use fat transfer at the breast level, starting initially in reconstructed breasts. Since 1998, fat transfers to the thoraco-mammary region have become one of our main research and evaluation themes. Choosing this theme of research was at the time courageous and reckless, because it attacked a powerful taboo and the assertive opinion of the tenors of the French and American Scientific Societies. In 1998, we first applied fat transfers to breast reconstruction using the Latissimus dorsi flap without prosthesis. In fact, in the plastic and reconstructive surgery unit, I had developed this technique of autologous breast reconstruction using a latissimus doors flap without prosthesis (called autologous latissimus dorsi flap). This autologous breast reconstruction technique made it possible to reconstruct a satisfactory breast volume in 70% of cases, but in 30% of cases, the volume was insufficient and it was then necessary to reduce the contralateral breast, or to add an additional prosthesis which removed the purely autologous to breast reconstruction, and brought disadvantages of prostheses (less natural form and consistency, need for change of prosthesis, risk of infection). I then began the application of fat transfer in the breast reconstructed by latissimus dorsi flap, in which the risk of local recurrence was considered very low. We called this technique lipomodelling of the breast (lipo – the Greek word for fat, and modelling from the Italian modello, which means to give a shape or a relief; this being exactly the definition of the surgical gesture that we do in this operation) in order to start on new bases++++, and not have to bear the full weight of the past controversy on lipofilling. The protocol was initially proposed to volunteer patients who agreed to undergo strict surveillance. Then, noticing the significant efficiency of this technique, and the absence of negative side effects, we have extended the indications to the majority of patients with autologous latissimus dorsi flap breast reconstruction wishing an optimal result in shape and consistency, and with a cleavage as natural as possible. The surgical technique was developed, refined to allow the fat transfer in large quantities (concept taken up by American authors under the term megavolume fat grafting), without significant fat necrosis. In parallel, mammographic, ultrasound and MRI studies were carried out, which showed that the impact on mammary imaging was not unacceptable, on the contrary. We then progressively expanded the indications of lipomodeling to different situations of breast reconstruction (breast reconstruction with TRAM, reconstruction by prostheses, reconstruction by lipomodeling exclusively), then to the malformations of the breast (tuberous breasts since 2000, Poland’s syndrome since 2001), and sequelae of conservative treatment since 2002; and lastly, cosmetic breast surgery.
The first presentations at the French Society of Plastic and Reconstructive Surgery (SOFCPRE) in Paris in 2001, in Milan in 2001, and at the level of the global society (IPRAS) in Sidney in 2003 gave rise to very critical comments, which are still not forgoten, with a lot of aggressiveness and unfriendly frontal attacks, taking up the hostile elements of the polemic of 1987. We responded point by point with scientific arguments +++, then gradually by presentations to the SOFCPRE, and to many congresses around the world (see scientific references), the hostility of the community decreased day by day. Other pioneers of fat transfers on the breast followed the same path, and confirmed our preliminary results. These include: Sidney Coleman in New York, Gino Rigotti in Italy, Roger Khouri in Miami. Sidney Coleman, a pioneer of modern fat transfer at the face level, applied the lipostructure technique to the breast, and published an article in the 2007 Plastic and Reconstructive Surgery Journal in which he recounted his experience of 17 cases. This article confirmed our work, showing the effectiveness and safety of this approach, and invited the American Society of Plastic Surgery to reconsider its position in regards to the fat transfer in the breast. Gino Rigotti, in Italy, since 2002, began to use fat transfers in the breasts, especially in the sequelae of radiotherapy. His work is now well known worldwide, especially following an article in the American Plastic and Reconstructive Surgery Journal of 2007 in which he confirmed the effectiveness of fat transfer in radiation sequelae, and he insisted on its effectiveness because of the adipose origin stem cells supply, which repair strictly speaking the tissue lesions related to the rays. We also discovered the same findings and that is why in 2006 we created together with Véronique Maguer-Satta a research team to study breast stem cells and stem cells of adipose origin (see chapter “perspectives for the future”). Seeing our work at a congress, Roger Khouri had the idea to combine since 2006 the fat transfers with the Brava, external expansion device he had invented at the end of the 90s, and which was ideally applied here, the Brava distending the mammary tissues, and the lipomodeling filling the space thus created (see Chapter BRAVA).
Many studies have since confirmed the effectiveness of fat transfer in breasts and in various other applications. An international scientific society called ISPRES (International Society of Plastic Regenerative Surgery), of which we are a founding member, was created to study the many possible applications of fat transfer, and held its first meeting in Rome in March 2012. Fat transfers are now recognized as part of the therapeutic arsenal for breast reconstruction, sequelae of conservative treatment, breast malformations and mammary hypotrophy, and are considered highly effective by the scientific community, being probably the major breakthrough of the last 20 years in plastic, reconstructive and aesthetic surgery of the breast. We are happy to have stood firm despite criticism and adversity, and to have been able, through the quality of our scientific work and our intuitive obstinacy, to bring the application of fat transfers at breast level; this represents a major improvement for patients in need for reconstructive or aesthetic surgery. This approach is now recognized by the French and international scientific community. A recent meta-analysis (2018) confirmed the safety and efficacy of this technique. In France, it has been evaluated by the HAS (Haute Autorité Sanitaire) in order to confirm the “Adipose tissue autograft in plastic, reconstructive and aesthetic surgery”. The HAS revealed its report in January 2015. This remarkable multidisciplinary scientific report confirmed the major breakthrough represented by fat transfers in the breast, and confirmed the safety and remarkable contribution of this technique. The report was sent to the Health Insurance to set up a reimbursement of these interventions in case of reconstructive surgery. The administrative and medico-administrative process has been quite lengthy, and has now resulted in the establishment of 2 specific CCAM codes under the term “Adipose Tissue Autograft at the breast” (QEEB317 for transfers of less than 200 cc, QEEB152 for transfers of more than 200 cc) for reimbursement of this intervention. These codes have been in effect since October 1, 2017. Given the state of finances of the Health Insurance, reimbursement is of course not very high, but it allows to work with specific codes, finally adapted to our surgical practice, and especially to the needs of our patients +++, in case of reconstructive surgery.