Breast Surgery

Special Topic ON
AL CON

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INT ATI

IBUTION
Patient Information Before Aesthetic

ERN
Lipomodeling (Lipoaugmentation):
A French Plastic Surgeon’s Perspective
Emmanuel Delay, MD, PhD; Raphael Sinna, MD; Thomas Delaporte, MD; Gérard Flageul, MD;
Christian Tourasse, MD; and Gilles Tousson, MD

Fat grafting to the breasts has long been controversial among aesthetic surgeons. We have developed a new,
safe, effective, and reliable lipomodeling method to be used in breast augmentation. This method grew out
of our clinical and radiologic experience acquired since 1998 with fat injections to the breast. The aim of the
present report is to provide facts and data concerning lipomodeling and to document our procedures for
ensuring that clear, consistent, up-to-date information is given to the patients who are undergoing aesthetic
lipomodeling. The key element in our preparation is our commitment to avoid missing the diagnosis or alter-
ing the presentation of a preexisting or newly arising breast cancer. We must also ensure that the patient
understands the need to comply with follow-up recommendations, such as a specific radiologic examination
before and one year after the procedure, as well as a biopsy evaluation of any lesion that is considered suspi-
cious during the physical examination. The patient must sign a confirmation that she has received the appro-
priate information and that she understands the notice provided by the surgeon at her first visit. This notice
must deliver clear, complete, objective, evidence-based information, must be written clearly and understand-
ably, and must not contain any unrelated or confusing information. (Aesthet Surg J;29:386-395.)

Editor’s note:
In 2008, Société Française de Chirurgie Plastique
Reconstructrice et Esthétique (SOFCPRE) put into effect
a recommendation regarding lipomodeling of the breast.
According to the author, while it was not a moratorium,
they “did not recommend fat grafting in the native
breast other than in specialized teams (trained plastic
surgeons on the technique, efficient radiologists, et
cetera) conducting prospective studies on the subject.”
As the studies of Dr. Delay and his colleagues conform
to these recommendations, it did not change his prac-
tice of lipomodeling. Every patient undergoes screening
for malignancy, through x-ray, ultrasound, or MRI, and
injections are begun only after clearance by a radiolo-
gist. Patients are then followed up closely for any signs
of concern on imaging scans. The author recommends
that the guidelines of the SOFCPRE be followed and any
injections be performed in a secured environment.
Drs. Delay, Sinna, Delaporte and Tousson are from the Department of
Plastic and Reconstructive Surgery, University of Lyon, Lyon, France.
Dr. Flageul is a plastic surgeon in private practice in Paris, France.
Dr. Tourasse is a radiologist in private practice in Amiens, France.
B
reast prosthesis implantation is currently the gold
standard for breast augmentation.1,2 Until recently,
no other technique had been recognized as being
both safe and reliable by the community of plastic sur-
geons. Some groups have proposed other options derived
from the techniques used for breast reconstruction.3,4
Others have suggested the use of autogenous augmenta-
tion mammaplasty with microsurgical tissue transfer.5
Given that the requirements of aesthetic breast augmenta-
tion include minimal scarring, moderate surgical trauma,
and the absence of morbidity at the donor site, these tech-
niques do not seem appropriate for routine use in plastic
surgery. The literature also includes reports on the injec-
tion of various products into the breast. However, because
the administration of these exogenous substances may
induce allergic or immune reactions and complications,6
their use cannot be recommended at this time.
We have shown that lipomodeling is a safe and effec-
tive means of aesthetic breast reconstruction.7 We use it on
a daily basis in patients with cancer2,7,8 or for the correc-
tion of sequelae of breast conservative treatments,2,9 tuber-
ous breast deformity, and chest and breast deformations
associated with Poland syndrome.7 The major criticism of
our technique was the possibility that it might induce a

386 • Volume 29 • Number 5 • September/October 2009 Aesthetic Surgery Journal

modification of radiologic images that could hinder the
detection of cancer. We have tested the radiologic impact
of fat transfer on various breast imaging modalities,
including mammography, ultrasound, and magnetic reso-
nance imaging (MRI). We found no lipomodeling-induced
impairment of the breast radiologic image, provided that
the lipomodeling procedure is performed at a high techni-
cal standard and under strict radiologic control.9,10
This positive radiologic evaluation has encouraged us
to extend the lipomodeling technique to plastic surgery
of the breast. As is legally and ethically appropriate—
and required by French law—the patient must be thor-
oughly informed about the purpose and possible side
effects of any surgical procedure, and full informed con-
sent must be obtained.
In this paper, we summarize the history of fat injection
to the breast and provide a detailed explanation of our
means of providing the most complete and accurate infor-
mation possible to the patient. We also discuss obtaining
full informed consent. Special attention is paid to the risks
and complications attendant on this procedure and to the
issue of cancer as it relates to fat injection. The Appendix
(available online at www.aestheticsurgeryjournal.com) is
a reproduction of the patient information sheet.
A BRIEF HISTORY
The concept of fat grafting to the breast is not a new
idea in plastic surgery. In 1895, Czerny11 described the
first clinical case of breast reconstruction by transplanta-
tion of fatty tissues. Other authors later contributed to
the development of the technique.12-15
The technique was further refined by Bircoll,16 who
sparked a controversy with his work on cosmetic breast
augmentation, in which he used autologous fat and lipo-
suction techniques. In 1987, Bircoll and Novack17 report-
ed the case of a patient undergoing breast augmentation
by fat grafting for symmetrization after contralateral
reconstruction of the transverse rectus abdominis
myocutaneous (TRAM) flap.17 Several equally controver-
sial responses were published in the Journal of Plastic
and Reconstructive Surgery.18-20 Detractors considered
that autologous fat grafting was responsible for the for-
mation of calcifications and cysts that might possibly
interfere with the detection of breast neoplasms.
However, it is known that 10% of women are likely to
develop breast cancer at some point in their lives
whether they have undergone lipomodeling or not,21 and
Bircoll22 argued that cancer-related calcifications cannot
be mistaken for calcifications associated with fat trans-
plantation, because the two types of calcifications occur
at different sites and have different radiologic aspects.
In 1987, the American Society of Plastic and
Reconstructive Surgeons (ASPRS) stated the following:
“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 physio-
logical response to necrosis of this tissue is scarring and
calcification. As a result, detection of early breast carci-
Patient Information Before Aesthetic Lipomodeling (Lipoaugmentation)
noma through xerography and mammography will
become difficult and the presence of disease may go
undiscovered.” There were no explicit scientific findings
to support this view and the report only expressed the
opinion of the members of the committee. Despite the
lack of scientific evidence—and although it had long
been recognized that any mammary surgery can be
responsible for the occurrence of fatty cysts or/and
mammographic changes—the injection of fat into the
breasts became taboo among surgeons. Ironically, also in
1987, a retrospective study of mammographic changes
after breast reduction published in the same journal23
reported that calcifications were detectable in 50% of all
mammograms two years postoperatively.
Although its use in breast reconstruction was contro-
versial at that time, fat grafting was still being used for
facial rejuvenation or reconstruction.24,25 Considering
the very encouraging results obtained from its use in
facial surgery, we decided to apply the same technique
to breast reconstruction and focused our research on the
subject in 1998. First, we used fat grafting along with
autologous latissimus dorsi flap reconstruction.26,27 The
very satisfactory results obtained in our first patients
encouraged us to extend the method to other types of
breast reconstruction and then to apply the same tech-
nique to the management of patients with breast defor-
mities or sequelae of breast conservative treatment (and,
more recently, to breast augmentation).
Our first presentations before the Société Française de
Chirurgie Plastique, Reconstructrice et Esthétique
(SOFCPRE)28 and at the meeting of the International
Society of Plastic, Reconstructive and Aesthetic Surgery
in Sydney29 raised considerable debate. The discussants
revisited the issues raised in 1987, with many similar
criticisms. Point-by-point rebuttal and further presenta-
tions of our work gradually dispelled the opposition of
our colleagues. The senior author’s (ED) experience now
includes more than 880 lipomodeling procedures, of
which 734 were performed for breast reconstruction, 106
for the correction of congenital deformities, 30 for aes-
thetic breast surgery, and 10 for the correction of previ-
ous surgery defects. As our first patients have been
followed for 10 years, reliable data on long-term follow-
up are available.
CONSULTATION WITH THE SURGEON
Preoperative consultations are a critical step for patients
undergoing autologous fat transfer for breast reconstruc-
tion. As is the rule in plastic surgery (as and is required
by French law), the patient is entitled to receive precise,
complete, and up-to-date information about the different
aspects of the procedure.
Because lipomodeling has been only recently intro-
duced in breast plastic surgery, the information given to
the patients must include both the state of scientific
knowledge on the subject and the potential uncertainties
of the technique. Appropriate selection and prioritization
of the information is necessary to help them make an
Volume 29 • Number 5 • September/October 2009 • 387
informed decision and give properly informed consent.
We have selected and organized the information that we
consider crucial to the decision-making process. Our
purpose is purely didactic; we do not intend to provide a
rigid frame for the medical consultation, but only to
emphasize some landmarks that we think should be of
interest at each step of the process.
The main principles of the preoperative consultation
before aesthetic lipomodeling are as follows: (1) iden-
tifying the patient’s expectations; (2) analyzing each
individual case; (3) providing information on the dif-
ferent treatment options; (4) describing the major
steps of the procedure; (5) describing achievable out-
comes; (6) describing potential risks and complica-
tions; (7) addressing issues relating to fat grafting and
cancer detection; (8) providing other information of
interest; (9) describing follow-up care; (10) ensuring
sure that the patient understands the information
delivered to her; and finally, (11) providing accurate
financial data with a detailed estimate of costs.
Identifying the Patient’s Expectations
Any gap between patient expectations and the practical
limits of surgery may naturally affect the patient’s satis-
faction with the procedure.30 Benefits and limitations
must therefore be made very clear beforehand. In partic-
ular, the patient must be told that fat grafting cannot
totally replace breast prosthesis placement; the indica-
tions for the two procedures vary with the type of mor-
phologic change needed (volume of the breast,
underlying muscles) and with the donor site (volume of
fat cells available for harvesting).
Because of these limitations, the surgeon must help
the patient to reformulate any unrealistic, unattainable
expectations. This is particularly true because the proce-
dure, which combines liposuction of excess fat and aug-
mentation of small-sized breasts, may appear very
attractive and seemingly magical to many women; there-
fore, it could raise unrealistic expectations. Fortunately,
today’s patients are generally well–informed. They are
able to access and understand the information now
available through advances in communication, such as
the Internet. They can usually verify the information giv-
en to them by the physician and assess its usefulness.
They can also assess the quality of the explanations and
care provided by the surgeon, along with his or her
understanding of their needs. This is why it is crucial to
provide complete, accurate, and timely information at
every step of the procedure.
Analyzing Each Individual Case
Indication for surgery is based on a detailed case history,
on the patient’s familial and personal medical history,
and on a complete clinical investigation. Any personal or
family history of breast malignancy should be evaluated
in all patients undergoing plastic surgery of the breast.
This information is critical not only to assess the indica-
tion for surgery, but also to decide whether a more in-
388 • Volume 29 • Number 5 • September/October 2009
depth preoperative evaluation should be provided. This
is particularly important because patients with any his-
tory of breast malignancy are prone to fat cell necrosis
and are at a higher risk of developing breast cancer.9
This focus on each patient’s individual case is a cru-
cial step of the procedure. The surgeon has a responsibil-
ity to provide the patient with accurate information
about her status at the time of the visit; therefore, any
sign or condition possibly interfering with the procedure
or its result (and thereby influencing the final decision of
the patient) must be taken into consideration and dis-
cussed. For instance, an important focal point is the vol-
ume of fat cells available for harvesting, which is often
the limiting factor of the technique. Similarly, the indica-
tion for fat grafting will be discussed as a function of the
initial shape of the breast: patients with breast ptosis
who desire both mastopexy and augmentation can bene-
fit from the procedure, but they must be aware that the
degree of augmentation will be reduced, because most of
the fat will be injected into the pectoralis major muscle
and the upper breast quadrant to restore cleavage.
Providing Information on Different Treatment
Options
The Agence Française de Sécurité Sanitaire des produits
de Santé—the French equivalent of the US Food and
Drug Administration—recommends that the patients
receive information on all available treatment options.31
In France, the most frequent alternative to fat grafting
for patients who desire aesthetic breast augmentation is
the placement of silicone gel–filled implants. The bene-
fits and drawbacks of both options must be discussed
and compared with the patient. Other options, such as
saline or hydrogel implants, are also available (although
they are less common) and must also be mentioned.
Describing the Major Steps of the Procedure
A detailed description of the surgical procedure and
treatment modalities must be given to the patient. This
includes date and hour of hospital admission, one-day
hospitalization (outpatient clinic), and general anesthe-
sia. Apart from usual preoperative evaluation (biologic
work-up and consultation with the anesthetist), a pre-
cise radiologic evaluation of the breasts (digital mam-
mography and ultrasound) must be performed by an
expert radiologist skilled in breast imaging and in the
examination of augmented breasts. Whenever possible,
preoperative and postoperative evaluations should be
performed by the same radiologist.
Preoperative radiologic evaluation is essential to mini-
mizing the risk of concomitant cancer in patients under-
going fat grafting. Images also serve as a reference for
subsequent follow-up examinations. The precise data
gathered from systematic pre- and postoperative work-
up can be used for further retrospective studies and
objective assessment of the technique. In the absence of
suspicious findings, follow-up examinations will include
only a digital mammography and ultrasound examina-
Aesthetic Surgery Journal
tion, at a frequency determined by the radiologist
responsible for the one-year follow-up evaluation.
Describing Achievable Outcomes
Fat grafting cannot completely replace breast prosthesis
placement. The indications for the two procedures are
different. Prosthesis placement is most appropriate for
women who desire large breast augmentation and com-
plete reshaping with round, firm, bulky breasts. Fat
grafting is more appropriate for women who desire only
moderate breast augmentation or those who simply
want to restore their earlier contour (after weight loss,
pregnancy, or breastfeeding). It is also recommended for
women who wish to obtain more “natural” results, with
no sensation of a foreign body in their breasts. Of
course, the method is not an option in women who have
insufficient fat deposits available for liposuction.
Consequently, as mentioned before, the surgeon must
identify the patient’s needs and expectations and make
sure that she understands the possible limitations of the
technique. In addition, the results of liposuction at the
donor site are also a factor in the patient’s overall satis-
faction with the procedure. If she subsequently loses
weight, her breasts may get smaller and she may become
disappointed with the results locally. In such cases, it is
important to emphasize the benefit obtained at the donor
site (ie, the abdominal region or the thighs).
It is also important that the patient be aware of the
degree of uncertainty associated with the results of the
procedure. The fat cells grafted to the patient may not
survive. It is generally necessary to account for approxi-
mately 30% fat resorption postinjection. In our experi-
ence, this rate is actually between 30% and 40%. To the
patient, it may seem more like 50%, because she usually
compares the final result with the volume of her breasts
in the immediate postoperative phase, when the grafted
site is swollen and edematous. (A comparison with pre-
operative photographs can help minimize possible
patient disappointment with the results.) This is why the
surgeon needs to mention the risk of further breast thin-
ning and insist that the patient must maintain a stable
weight postoperatively (because losing weight inevitably
results in a loss of breast volume).
Describing the Risks and Complications
French jurisprudence recommends complete information to
the patient by the surgeon about all risks and possible
adverse consequences of surgical treatments. This informa-
tion concerns all risks known to the medical community
that a reasonable patient would consider material to the
decision of whether or not to undergo the procedure. These
risks are, however, difficult to determine. Our current tech-
nique for aesthetic breast lipomodeling is relatively new.
Moreover, although many surgeons performed lipomodel-
ing in the past, relatively little has been published in the lit-
erature about fat grafting to the breast and its potential
complications, in part because of the taboo previously asso-
ciated with the use of fat grafting for breast augmentation.
Patient Information Before Aesthetic Lipomodeling (Lipoaugmentation)
It is usually the role of medical and scientific societies
to provide updated information on the most common
techniques. There is considerable information available
and experts from scientific societies are the most likely to
decide which information is relevant and should be made
available to the patients. To fulfill that goal, experts must
examine the different options with an objective and criti-
cal eye. Our experience with the different drawbacks and
complications of breast lipomodeling is outlined below.
Postoperative Issues. Postoperative issues in lipomodeling
are similar to those developing after liposuction, with
patients complaining of pain, bruises, and swelling. Pain
is mild and generally amenable to standard pain medica-
tion(s). The procedure causes inflammation and
swelling, with a peak between 24 and 48 hours post-
surgery. Most of the swelling resolves within one month
and is completely (or almost completely) controlled
within three months postoperatively. The patient must
be informed that bruising will probably occur at both
the donor site and at the graft site.
Complications. Serious complications of fat grafting
are rare, as shown in procedures performed at other
body sites.32-35 Although it is the most common com-
plication of surgery, hematoma is extremely rare in
patients undergoing fat grafting to the breast. So far,
none of the 850 patients treated by the first author
(ED)—including all fat transfer indications—has ever
experienced a hematoma.
The risk of pneumothorax is low. This complication has
been reported in only one of our 850 patients who had
undergone lipomodeling after postmastectomy latissimus
dorsi breast reconstruction. Fat cells had been injected per-
pendicularly to the thorax wall to increase breast projec-
tion. The diagnosis of pneumothorax was confirmed
radiographically after two episodes of oxygen desaturation
(during and immediately after the surgical procedure). A
pleural drain was inserted to restore normal saturation and
the patient returned to her previous clinical condition,
with no long-term consequences with respect to the results
of lipomodeling. To prevent this complication, we recom-
mend that fat grafting for improvement of periareolar pro-
jection should systematically be performed upward, in
parallel with the chest wall, from two incisions made in
the inframammary crease.
There is a theoretical risk, often put forward by
detractors of the procedure, that fat cells can be injected
in a vessel and cause fat embolism.36 To avoid this com-
plication, it is advisable to use side-port cannulas and to
perform injections while gently pulling the cannula off.
No instance of fat embolism was encountered in our
series of 850 patients.
The major short-term complication is infection.
However, there have been exceptionally few reports of
infection (principally at the graft site) in the literature
published on fat grafting for other indications. Chajchir
and Benzaquen34 reported no infection in their series of
253 patients. Of 145 patients treated by Fulton37 (corre-
sponding to 399 injections), only three developed infec-
Volume 29 • Number 5 • September/October 2009 • 389
 A B

C D
Figure 1. A, B, Preoperative views of a 28-year-old woman with bilateral hypotrophy associated to moderate tuberous breasts. C, D, Twelve
months after two lipomodeling sessions (first session: 250 cc to the right breast, and 90 cc to the left; second session six months later: 320
cc to the right and 210 cc to the left).

tion at the graft site. As for the 1350 patients treated by de
Pedroza,35 infection developed in only one (overall infec-
tion rate 0.07%), which resolved after the administration
of antibiotics. We consider the best preventive strategy
against infection to be strict asepsis and proper antibiotic
prophylaxis during the procedure. There may be signs of
infection, with local redness in the breast area. Removal
of the graft suture may result in the loss of a little murky,
fatty fluid, but the reaction is generally successfully con-
trolled with antibiotics and the local application of ice.
Only six of the first author’s 850 patients have developed
moderate, transient superficial infection in the breast area.
One had an infection in the umbilical area (near the lipo-
suction site), but the local redness promptly resolved with
antibiotic therapy and ice.
Long-term complications are mainly fat necrosis and
irregular body shape at the donor site. Fat necrosis may
occur when excess fat cells are forced into already satu-
rated breast tissues, resulting in firm nodes possibly
amenable to puncture. The radiologic aspect of necrosis
varies from oil cysts to complex, multilocular, liquid or
semisolid cystic masses, but necrotic lesions generally do
not interfere with cancer diagnosis.38 Puncture generally
yields a thick, yellowish, acellular fluid. Fat necrosis is
less frequent when the procedure is performed by expe-
rienced surgeons. The incidence decreases from 15%
with inexperienced surgeons to 3% with more skilled
ones (several hundred cases or more), provided that the
two major principles of the grafting procedure—namely,
the use of a three-dimensional grid pattern and discon-
tinuation of fat grafting when the tissues are saturated—
are satisfied.1,7
Defects at the donor area may be caused by the irreg-
ular suction of fatty tissue. This is why we recommend
performing a minilipoaspiration that smoothes the area
and increases the patient’s overall satisfaction with the
procedure. The experience acquired with liposuction is a
valuable asset for minimizing the risk of complications
and achieving the best aesthetic results possible. The
current recommendations correspond to the practice of
experienced plastic surgeons working in optimal surgical
conditions. It must be kept in mind that breast aesthetic
lipomodeling is a full-fledged surgical operation, that it
deserves the same care and attention as other plastic

390 • Volume 29 • Number 5 • September/October 2009 Aesthetic Surgery Journal

surgery procedures, and that it must always be per-
formed by a skilled plastic surgeon who is experienced
with the technique.
Defective Results. When the indication is appropriate and
the procedure is performed correctly, breast lipomodel-
ing provides real improvement and generally achieves
the postoperative results that patients expect (Figure 1).
In some cases, a second session, under general anesthe-
sia, is necessary to improve the shape of the breast.
Experience with breast reconstruction and reshaping
makes it possible to predict (or at least imagine) the
final result. The number of sessions may vary and the
volume of fat deposits available for collection may also
vary within reasonable limits. When two sessions are
needed, the patient should be informed beforehand to
avoid misunderstandings and disappointment. Similarly,
she should receive detailed information on the costs
incurred in order to eliminate all potential sources of
financial disagreement. In some rare cases, local defects
may still be observed, including local undercorrection,
mild asymmetry, or irregular shape. Again, a second
lipomodeling session performed under local anesthesia
can be attempted when the result is stable (three or four
months postoperatively).
Addressing Fat Grafting and Breast Cancer Issues
The Patient’s Personal Risk of Developing Breast Cancer.
In France, the risk for a woman to develop breast cancer
is approximately one in 10.39 Breast cancer screening
and diagnosis are therefore major issues.
The purpose of the initial work-up before lipomodeling
is to confirm that there is no suspicion of breast cancer
before initiation of the procedure, in order to minimize
the risk of coincidence between cancer and fat grafting.
Patients undergoing lipomodeling must be fully aware of
their risk of breast cancer. The clinician can help them by
using the Gail risk evaluation.40 They must also be aware
that the breast imaging work-up performed before lipo-
modeling is essential in determining the risk of concurrent
malignancy. In addition, all patients must make a commit-
ment to undergo imaging follow-up at one, two, and pos-
sibly three years postoperatively, depending on the
recommendations of the radiologist.
Finally, patients must be informed that, if they ulti-
mately develop breast cancer, they will benefit from the
same treatments as patients who are diagnosed under
circumstances other than breast lipomodeling follow-up.
Risk of Cancer Dissemination Caused by Fat Grafting.
The potential risk of dissemination of cancer cells by fat
grafting is similar to the risk attributable to cancer biop-
sies. The first needle core biopsies of cancer lesions pro-
voked similar debate and there are now sufficient data to
show that the risk of cell migration is important, with
some studies reporting rates of migration as high as
30%.9,38,41,42 It has even been shown that cancer cells
are able to migrate to the axillary lymph nodes, but with
few clinical or prognostic consequences for the
patients.43 The risk of displacement is principally related
Patient Information Before Aesthetic Lipomodeling (Lipoaugmentation)
to the type of tumor and the time interval between biop-
sy and surgery. Other parameters, such as the volume or
the grade of in situ or infiltrating carcinomas and lymph
node involvement, have no significant impact on tumor
cell migration.41 The most invasive cancers are actually
infiltrating lobular carcinomas, infiltrating ductal carci-
nomas, and in situ carcinomas.41
Interestingly, the frequency of tumor displacement is
inversely related to the time interval between biopsy
and surgery. Sometimes, when patients undergo late
surgery, no tumor cell is found.44 These data suggest
that, contrary to sarcoma or ovarian cancer cells that
may give birth to a secondary tumor at the site of in-
jection, breast tumor cells displaced by the needle are
fragile and do not survive after the procedure. No corre-
lation has been shown between tumor biopsy and re-
currence.45 It is clear from the literature that this
mechanical transfer of cancer cells may lead to confu-
sion in the interpretation of histologic data, such as the
overestimation of the size of a small infiltrating carcino-
ma, the erroneous diagnosis of infiltrating carcinoma
when cells from an in situ tumor are disseminated
throughout the stroma, or even the erroneous diagnosis
of lymph node involvement.
As is the case for biopsies, it is reasonable to think that
cells detached from a small tumor undetected by preoper-
ative work-up and displaced by fat grafting will not sur-
vive after the procedure. Breast cancer cells are fragile and
the dissemination of cancer by lipomodeling is therefore
very unlikely, as confirmed by the case of one of our
patients who underwent fat grafting for breast reconstruc-
tion. At the time of the procedure a local recurrence was
developing in this patient; this had gone undiagnosed in
the preoperative work-up. The local recurrence was
detected soon after the procedure, and a mastectomy was
performed. Histologic examination of the surgical speci-
men revealed no dissemination of the tumor to other
quadrants of the breast.9 These results should be con-
firmed on larger retrospective series of patients.
Contribution of Lipomodeling to the Early Detection of
Breast Cancer. As is generally the case with breast surgery,
lipomodeling modifies the structure and therefore the radi-
ologic aspects of the breast. One of the most debated
issues is the risk that fat grafting might confuse radiologic
screening tests and hinder breast cancer detection.
In the authors’ experience, this risk is very low. Only
one of our patients developed a breast tumor and she
was treated quickly.9 The procedure may even some-
times accelerate cancer detection because the patients
undergoing lipomodeling are kept under strict radiologic
control and close postsurgical follow-up.
There are three major concerns when performing fat
grafting to the breast: technical considerations, follow-
up modalities, and the management of postlipomodeling
breast modifications. Very few authors have explored
the technical aspects of the procedure or the outcome
of the fat cells grafted to the patient using strict method-
ologic criteria.
Volume 29 • Number 5 • September/October 2009 • 391
 There is no standardized procedure for fat grafting to
the breast. Virtually every surgeon who performs this
procedure uses a different technique.46 Very little
research has been done involving a large clinical series
and most reports on fat necrosis describe isolated clini-
cal cases. In addition, postlipomodeling swelling cannot
be systematically attributed to fat necrosis. In our experi-
ence, modern fat grafting techniques induce little or no
fat necrosis.1,7 As mentioned previously, the develop-
ment of any such necrosis47 is probably a telltale sign of
technical flaws during the procedure.
Whatever the technique or the clinical situation, care-
ful breast monitoring is mandatory: clinical examination,
surveillance of lesions (such as occurrence of skin wrin-
kles, shrinkage, or palpable lumps, nipple retraction, and
diffuse inflammatory reactions) and signs of progression
(such as a malignant lesion not resolving spontaneous-
ly). Mammography remains the most accurate tool for
breast cancer detection and screening. Based on equivo-
cal mammography or ultrasound findings, some studies
have banned the use of fat grafting for breast augmenta-
tion on the grounds that calcifications and fat necrosis
might delay or prevent cancer detection and treat-
ment.48,49 In reality, mammography is a very sensitive
tool and radiologists can generally distinguish calcifica-
tions caused by surgery from those that are indicative of
breast cancer.50
The clinical management of breast modifications is
always the same, whether they occur after lipomodeling
or in nonoperated breasts. The diagnosis of cancer must
be confirmed histologically by percutaneous needle
biopsy. Cytologic aspiration is simple and rapid, albeit
with low sensitivity and specificity. Aspiration may yield
acellular material of no diagnostic value and cannot be
relied upon to determine tumor extension (either in situ
or infiltrating lesions). Only needle biopsy can provide
nearly as much information as surgical biopsy. This is
why a needle biopsy should be systematically performed
in all patients who present with swelling breast lesions
or with atypical and probably malignant radiologic
images. Our conclusion is that lipomodeling does not
hinder early cancer diagnosis, especially when strict pre-
and postoperative control is performed.
On the contrary, we believe that lipomodeling could
facilitate cancer detection over time. Our hypothesis is
that when the procedure is performed correctly, the
mammographic density of breast tissues decreases and
screening for breast cancer becomes easier, thereby
allowing for earlier detection of the disease. This hypoth-
esis is supported by radiologists who believe that “fat is
their ally” because the fat graft remains radiologically
clear, which greatly enhances contrast and facilitates the
detection of abnormalities. Confirmation of this hypothe-
sis should be obtained from a large-scale study focusing
on this issue.
However, it should be impressed upon patients that
radiologic examination of the breast has its limitations
and, as reported in several of our patients,9 the
392 • Volume 29 • Number 5 • September/October 2009
absence of radiologic evidence of cancer (on mammog-
raphy, ultrasound, or MRI) is not necessarily equiva-
lent to the absence of cancer. Approximately 8% of
breast cancer patients have normal mammographic
findings51,52 and 3% have both normal mammographic
and sonographic findings.53
Protective Effect of Fat Grafting? Although we do not as
yet have the observational evidence to prove it, our cur-
rent research on fat-derived stem cells seems to indicate
that these cells might exert some antitumor activity. If
this intuitive expectation is confirmed by further study, it
would show a possible protective role of fat grafting in
defending against breast cancer. In addition, breast
mammographic density is widely accepted to be an
important independent risk indicator for the develop-
ment of breast cancer54-57 and even represents a risk fac-
tor for cancer in itself. It seems logical to assume that
reducing breast tissue density by grafting fat cells may
also help reduce the risk, probably via an indirect posi-
tive effect on stromal cells, which are known to be large-
ly involved in the development of breast cancer.
Education of Breast Imaging Radiologists and Experts.
Misinterpretation of the potential causal relationship
between breast cancer and fat grafting is easy to under-
stand. It is a common mistake to jump too quickly to
conclusions based on outdated or erroneous information
and there has long been a prejudice against fat grafting.
The central issue seems to be the level of knowledge and
training of experts and radiologists involved in breast
imaging. On May 12, 2007 and June 7, 2008, two meet-
ings that focused on breast imaging after plastic surgery
and, more specifically, after breast lipomodeling
(“Imagerie du sein et chirurgie plastique”) were organ-
ized in Lyon, France, for the purpose of sharing “best
practices” among breast imaging radiologists. Experts
unanimously confirmed that fat grafting to the breast is
not responsible for errors or delays in breast cancer diag-
nosis. We believe that radiologists involved in the diagno-
sis of breast cancer (or of breast cancer recurrence when
lipomodeling is intended for reconstruction after conser-
vative cancer treatment) should be well-informed and
trained specifically in the interpretation of breast images
after fat grafting. Moreover, after a breast tumor has been
diagnosed in a given patient, the radiologists should
make sure that they introduce no unwarranted assump-
tions with respect to any causal connection between can-
cer and lipomodeling.
Experts in plastic surgery and oncology should also
receive the same training. They must have a sufficient
scientific understanding of lipomodeling to convincingly
discount the controversies that will inevitably occur
again on this issue (because cooccurrence between can-
cer and fat grafting is relatively frequent and because so
many cancer patients feel depressed and view their situ-
ation as unfair), and to refute the suggestion of a rela-
tionship between fat grafting and the occurrence or
recurrence of breast cancer. This point is particularly
important because many people remain wary of the pro-
Aesthetic Surgery Journal
cedure; any hostile, unfriendly, or inappropriate word
from expert professionals might aggravate a situation (ie,
an occurrence of breast cancer or relapse) that is already
stressful for the patient and would serve only to exacer-
bate their distress. It is essential to avoid unnecessary
alarmism and to preserve the peace of mind of both the
patients and the physicians involved.9
There is no reasonable basis to establish a correlation
between the occurrence of breast cancer and a history of
fat grafting to the breast. However, as the procedure is per-
formed more often, the number of coincidences is obvi-
ously going to grow. This is why radiologists should be
fully aware of the risk, be able to make an early diagnosis,
and be able to adapt their communication accordingly.
Providing Information on Other Issues of Interest
Microcalcifications. Calcifications are a normal conse-
quence of lipomodeling2,9,10,38 and of any standard breast
surgery.23,58,59 A recent small series of 17 nonhomoge-
neous plastic surgery patients undergoing fat grafting for
aesthetic enhancement or breast reconstruction found
that 27% of patients had some sort of calcification.58
Whatever the surgical procedure, calcifications have no
diagnostic or therapeutic significance and are usually
noncancerous.23 There is no or little literature and virtu-
ally no systematic research on the occurrence of calcifi-
cations after lipomodeling. On the other hand, it has
been shown that 50% of patients undergoing breast
reduction surgery have calcifications within two years of
the surgical procedure,23 but it has never been suggested
that breast reduction surgery might interfere with cancer
diagnosis. Calcifications caused by fat cell necrosis are
easily recognizable; these usually benign, dystrophic cal-
cifications are easily distinguishable from calcifications
indicating breast cancer.23,59 Three different studies con-
ducted by our group have assessed the radiologic impact
of fat grafting in patients undergoing breast lipomodeling
after latissimus dorsi flap reconstruction10 for the correc-
tion of breast conservative treatment sequelae2,9,38 or for
the correction of breast deformity. All three studies have
shown that lipomodeling has no deleterious conse-
quences for breast follow-up or radiologic detection of
malignancies. As reported above, the conclusion of the
two meetings in May 2007 and June 2008 was that there
is no increased risk of missing the diagnosis of cancer
after fat grafting to the breast when the procedure is per-
formed by a skilled surgeon. On the contrary, some of
the experts, as mentioned above, even reported that “fat
is the radiologist’s ally” because the fat graft remains
radiologically clear, therefore enhancing the contrast and
facilitating the detection of abnormalities.
Breastfeeding. There is currently no known contra-
indication to breastfeeding after fat grafting. Because the
surgeon uses autologous fat cells similar to those present
in the natural breast, there is no risk of functional
changes that would forbid breastfeeding. However, it
must be noted that there are no statistical data available
to back up this information.
Patient Information Before Aesthetic Lipomodeling (Lipoaugmentation)
Describing Patient Follow-Up
Patients must be aware of the necessity to have a com-
plete imaging work-up before undergoing fat grafting in
order to rule out the risk of concurrent malignancy. They
must make a commitment to undergo imaging follow-up
at one, two, and possibly three years postoperatively, as
recommended by the radiologist. They must also arrange
a visit with the surgeon after one year, making sure that
the radiological follow-up has been correctly carried out.
Careful breast follow-up with complete clinical and
radiologic examination of the breasts is mandatory, inde-
pendently of the clinical context (aesthetic or reconstruc-
tive surgery).
Ensuring That Your Patient Fully Understands the
Information Given
In France, physicians are required to provide as much
information as possible so that the patients can make an
informed decision about their disease and treatments. In
accordance with the code of public health, “all patients
are entitled to receive information and must be given an
opportunity to participate in their own healthcare deci-
sion-making. No medical decision can be taken and no
treatment can be started without free and voluntary
agreement from the patient involved. This agreement
can be cancelled at any time” (law L. 1111-4, section 1).
Each patient must receive clear and unequivocal
information sufficient to enable her to weigh the
risk–benefit ratio associated with the procedure. To
avoid hasty decisions, the law requires a “cooling-off”
period before the patient can make any decision to par-
ticipate. In accordance with French law, it is the respon-
sibility of the surgeon to make sure that the patient fully
understands the information delivered to her. How can
surgeons show that the patient has both received and
understood the information?
As acknowledged by the law, there are many possible
ways of proving that the information has been correctly
delivered: the number of preoperative visits, length of
the “cooling-off” period, consultations with the attend-
ing physician, letters to the patient, information sheets,
or an informed consent form signed by the patient. It is
essential that the patients be given a written information
sheet before undergoing fat grafting. It is also desirable
that they sign a discharge form to show that they have
both read and understood the specific information deliv-
ered to them. Signing the form serves as both a legal
protection for the surgeon and as a psychological deter-
rent against further unjustified claims from the patient.
Providing an Accurate Cost Estimate
As for any other plastic surgery procedure, French law
requires that the surgeon provide a complete and
detailed estimate of the costs incurred by patients. The
estimate must also comply with all legal provisions rele-
vant to the particular situation, notably the compulsory
“cooling-off” period (15 days) between the drafting of
the estimate and the start of the procedure. When a sec-
Volume 29 • Number 5 • September/October 2009 • 393
ond session is necessary, the surgeon must produce a
second estimate or, if the same document is used, the
patient must give a second signature to confirm her
agreement. Providing detailed and precise information
on the costs incurred is useful for eliminating further
sources of financial disagreement.
CONCLUSIONS
We have explored the different elements of information
that must be given to the patients undergoing fat graft-
ing. A precise report of current clinical applications and
medical knowledge relating to fat grafting seems essen-
tial until the technique becomes more widely available
for aesthetic breast lipomodeling. However, to ensure the
accuracy and reliability of the information given, this
state-of-the-art report will need to be updated periodical-
ly as processes and procedures are changed or upgraded.
The key is to ensure that the patient understands that
the surgeon’s concern is accurate cancer screening and
that caregivers will not to overlook potential signs of
malignancy. The radiologic data gathered to date in
patients undergoing reconstructive fat grafting to the
breasts or the chest are satisfactory and encourage the
extension of the procedure to aesthetic breast surgery,
provided that it is based on a multidisciplinary collabo-
ration between surgeons and skilled radiologists.
It is reasonable to advocate the use of lipomodeling
for aesthetic breast surgery as long as the patient under-
goes a complete, specific radiologic evaluation before
and one year after the procedure, and as long as a histo-
logic biopsy is performed in cases where there is suspi-
cion of cancer during follow-up. The data recorded over
the years will also make it possible to perform multicen-
tric retrospective studies in order to evaluate the quality
and confirm the safety of the procedure.
Clinical information is a tripartite process: the first
person involved is the patient herself, as required by law;
the second is the surgeon, who must possess solid and
updated technical knowledge; and the third is the radiol-
ogist, who must be aware of the specific imaging features
associated with fat grafting to the breast. The quality of
the information process is crucial. The patient must
acknowledge (with her signature) that she understands
the purpose and possible risks and benefits of the proce-
dure, and that she has received clear, complete, objective,
evidence-based written information during her first visit
with the surgeon. This is why the information sheet must
be created with utmost care. The text of the patient infor-
mation document provided in the Appendix (available
online at www.aestheticsurgeryjournal.com) has been
carefully drafted and revised. It is readily available for
use by the community of plastic surgeons when seeing
patients who are candidates for breast lipomodeling. ◗
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