Dr. William Gerald Austen, Jr. (left), chief of Plastic and Reconstructive Surgery, is working to refine and improve the use of fat grafting for breast reconstruction. Barbara Smith (right), MD, director of the Mass General Breast Program, says addressing fears of disfigurement have a big impact on breast cancer recovery. Read more at massgeneralmag.org
Body fat usually makes headlines as a threat to human health but William Gerald Austen Jr., MD, has another perspective. As chief of Plastic and Reconstructive Surgery at Massachusetts General Hospital, he envisions it becoming a powerful weapon against breast cancer, albeit not as a treatment for the disease itself.
Dr. Austen’s focus is on helping women recover from related surgery. Using liposuction techniques, he and his Mass General colleagues are perfecting methods to harvest and process a woman’s own fat so that it can then be used in breast reconstruction. Similar forms of fat grafting are being offered in scattered places around the world, but Dr. Austen is refining the process to make it more effective and available. The goal is to dramatically reduce the need for manmade implants. In the meantime, Dr. Austen believes every successful step in that direction will mean breast reconstruction that is less complicated, longer lasting and more natural in appearance.
“We want to do it better and we want to do it more,” Dr. Austen says. “Ultimately, we’d like to be able to reconstruct an entire breast with a patient’s own fat, without doing a big operation. In the future, we see these as office-based procedures.”
Fat grafting is part of a broader Mass General effort to make breast cancer treatment less arduous and more beneficial for the patient. In recent years, breast cancer surgeons at Mass General have pioneered the use of mastectomies that spare the nipple, thereby improving opportunities for breast reconstruction. In many cases, plastic surgeons begin their work immediately after a patient’s mastectomy, reducing the need for more operations. Meanwhile, Mass General oncologists, cancer surgeons and plastic surgeons hold joint clinics to plot treatment strategies for individual patients, cutting down on the necessity for multiple office visits and giving patients a broader view of their treatment options from the start.
Barbara Smith, MD, director of the Mass General Breast Program, says a diagnosis of breast cancer sparks intense fears of disfigurement for many women. “If you can fix the disfigurement part, it has a big impact on the whole psychological tone of how a woman feels after she’s been treated for breast cancer,” says Dr. Smith, a breast cancer surgeon who works closely with Dr. Austen.
José Baselga, MD, PhD, chief of the Division of Hematology/ Oncology and associate director of the MGH Cancer Center, emphasizes that the point is to cure patients of breast cancer and help them get on with their lives. “It’s not all about life and death,” Dr. Baselga says. “It’s also about life and living well.”
Continued advances in detection and treatment of the disease itself make such a forward focus possible. Breast cancer remains the most common form of cancer for women, with an estimated 230,000 new cases diagnosed annually nationwide. But related death rates have been declining steadily since 1990. More women are living and thriving for many years after their initial diagnosis and treatment. Meanwhile, a growing number of women with medical factors that put them at higher risk for breast cancer are choosing to have their breasts removed as a preventative measure before the disease is actually detected.
In generations past, such trends would have seemed unthinkable. Well into the 20th century, the standard treatment for the disease was the radical mastectomy. A traumatic and disfiguring operation, it involved surgical removal of lymph nodes and chest-wall muscles as well as the breast. For patients, the physical and psychological impacts could be profound.
“The idea for most cancer patients, including breast cancer patients, was that the disease was so bad you should just be grateful to be alive when the treatments are done and that to kill cancer, you had to be aggressive,” says Dr. Smith. “Part of it was the philosophy that cancers grew gradually and that if you could do a big enough surgery, you could get around it.”
The use of radical mastectomies declined as researchers learned more about how cancer cells can break away and travel through the body, raising questions about the effectiveness of big, invasive operations. Treatment for breast cancer increasingly came to rely more heavily on radiation, newly discovered medicines and smaller operations, including lumpectomies, wherein only the tumor and a small amount of surrounding tissue are removed. Meanwhile, surgeons and researchers were developing more effective methods of breast reconstruction at the same time that advocates of women’s rights began demanding a reassessment of medical care for women. “People started saying, ‘No, I don’t want to lose my breast and it’s not okay to just take it off and not think about anything else,’” Dr. Smith recalls.
The first documented efforts at breast reconstruction date to the 1890s. While successful to varying degrees, all the methods developed in the decades since have their limitations. Using manufactured implants usually means a second operation after the mastectomy. With time, they often need to be replaced. Breast reconstruction using whole sections of tissue taken from other parts of a patient’s body, such as the abdomen, sometimes
creates significant recovery and scarring issues of its own.
Many women are perfectly happy with results achieved using such techniques. “But for many patients we’d really love to do better,” Dr. Austen explains. “For them, we need something in our arsenal that is not an implant and does not involve a huge operation.”
Plastic surgeons have long viewed fat grafting as an intriguing alternative for reconstruction. In theory, precisely harvesting and reinjecting a patient’s own fat should involve less scarring, a shorter recovery and a result that looks and feels more natural. Such fat grafting is done slowly with several procedures. But achieving a consistent and predictable result has been a challenge because, after grafting, some of the fat cells either die or are absorbed by the body.
As a result, the breast being reconstructed can shrink in mass and appearance in the weeks after grafting. For the patient, that means additional procedures to inject more fat. Much of the recent research by Dr. Austen and other Mass General plastic surgeons has been directed toward coming up with strategies to minimize and eliminate the problem and its associated costs.
Strengthening the cell’s outer membrane has been one focus.
In a study published last year in Plastic and Reconstructive Surgery, the journal of the American Society of Plastic Surgery, Dr. Austen reported that cells treated with a specific polymer were 50 percent less likely to die after fat grafting than cells that had not received such treatment.
Dr. Austen’s team has also looked closely at how fat is handled in the grafting process, aiming to zero in on the techniques that prove to be the most effective. For instance, fat harvested with a slightly wider surgical tube, or cannula, retains 25 percent more of its weight after grafting, according to one 2011 study by the Mass General group.
Minimizing the failure of fat grafts means a reduction in subsequent scarring and lumpiness, either of which might mask or be mistaken for a reoccurrence of cancer. Past concerns about such problems slowed the acceptance of such breast reconstruction, although experts say recent improvements in imaging technology have dramatically minimized that threat.
Even so, Mass General is moving ahead carefully, gathering data and honing techniques. Breast reconstruction through fat grafting may be a simple office procedure some day. But for now Mass General surgeons are using it to augment breast reconstructions involving manmade implants, or for surgical patients who haven’t actually had cancer. Dr. Austen also has a unique study involving fat grafting after lumpectomy.
Preschool teacher Megan Podraza, from West Greenwich, R.I., has a family history that puts her at high risk for breast cancer. After tests detected precancerous cells in her breasts, the mother of two decided to have a double mastectomy at Mass General in 2010. She got implants the following year but was self-conscious that they did not seem to fit her body’s natural contours.
Fat grafting by Dr. Austen allayed those concerns and has left Mrs. Podraza pondering the day when she might have her manmade implants totally replaced. The fat grafting procedure itself was simple and the results have been a big emotional boost, she explains. “Fat grafting really makes a difference in feeling maybe less artificial,” Mrs. Podraza says. “It’s very exciting for a woman like me.”
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