Saturday, January 17, 2009

Update from the 25th Annual Atlanta Breast Symposium....

I am excited to be attending the 25th annual Atlanta Breast Surgery Symposium.  This is the premier meeting dealing with advances in Plastic Surgery of the breast.  It is organized by many of my former colleagues from Emory University, where I spent 2 years in Plastic Surgery residency training from 1994-1996.  It is a forum for observation of live surgical procedures, exchange of ideas among international panel of plastic surgeons, and always a source of topical information that is directly pertinent to my daily practice.

Two interesting topics were discussed during the meeting.  Firstly, the role of nipple sparing or areolar sparing mastectomy for the treatment of breast cancer or for prophylactic mastectomy was reviewed.  While nipple and areolar reconstructive procedures have advanced significantly, it is still difficult to consistently reconstruct the nipple areolar complex to mimic the natural form in all cases.  The traditional oncologic surgical model considered removal of the nipple areolar complex vital for performance of a curative mastectomy in therapeutic cases, and necessary for complete risk reduction in prophylactic cases.  For several years, researchers have looked at the possibility of leaving the nipple areolar complex and studying the impact on local recurrence of cancer.  With certain criteria (involving tumors that are remote from the nipple areolar complex or less than a certain size, ) data is beginning to suggest that preserving the nipple areolar complex (or at least the areola) may not compromise the curative goals and can definitely improve the aesthetic outcome.  This is especially compelling since the role of prophylactic mastectomy has increased in the setting of BRCA genetic mutations, or during treatment of one breast, to reduce the chance of a new cancer developing in the untreated breast.  As I have observed in my own practice, and as many at the meeting have confirmed, bilateral mastectomy (where one breast is removed to cure the cancer and the other is removed so as to prevent cancer from developing in the other breast) is becoming much more common.  While this demands further study, women should definitely ask the breast and plastic surgeons about the role of nipple areolar sparing approaches in their particular case during initial surgical decision making.

The second topic of interest was the role of fat transfer or grafting in both cosmetic and reconstructive breast surgery.  It has been controversial to remove fat from one part of the body and add it to the breast solely from cosmetic enhancement of the breast size.  It was thought that the postoperative changes that could result from fat transfer might affect the ability to accurately interpret mammograms, and produce cysts or scarring in the breasts that would be confused with suspicious changes.  Fat transfer techniques have improved over the last decade, especially when used in facial rejuvenation.  If we can more reliably transfer living fat cells from one part of the body to the face, perhaps fat transfer could be re-examined for its role in the breast.  For several years, fat grafting to improve the results of breast reconstruction (such as adding fat to the tissues above an implant to soften the transition from the upper chest to the breast or to smooth the contours after flap surgery from breast reconstruction) have been done.  In fact, these are procedures that I do often for ultimate refinement in many of my breast reconstruction cases.

The main concern with fat grafting, especially for breast augmentation, is the possibility that the stem cells that are harvested in the fat, may release substances into the breast with unknown effect.  Might the transferred fat stimulate cancerous changes in breast cells in the future?  What about using fat transfer after mastectomy where the breast has been removed? Clearly, further study is needed, and board certified plastic surgeons are positioned to answer this question through further research.  I am optimistic about an increased role for fat transfer to the breast in the future.

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