Discussion: Clinical Analyses of Clustered Microcalcifications after Autologous Fat Injection for Breast Augmentation

Abstract

C is credited with the following quote: “If I am walking with two other men, each of them will serve as my teacher. I will pick out the good points of the one and imitate them and the bad points of the other and correct them in myself.” In this article by Wang et al., two very important themes emerge: (1) the variation in imaging techniques and interpretation of mammograms after breast fat grafting and (2) the marked variation in fat grafting surgical techniques. As plastic surgeons, we must reckon with the good and bad in both these themes. Dr. Wang and his coauthors, four plastic surgeons and one general surgeon, conclude, “The mammographic confusion constitutes the problem rather than the success of the procedure. . ..” If not mildly provocative, such a conclusion serves as a challenge for surgeons and radiologists to clearly delineate the nature of transplanted fat and how it may appear on postoperative radiologic imaging. European fat grafting pioneers, such as Emmanuel Delay, have recently pointed out the ability to distinguish between benign and malignant findings on post–fat grafting mammograms when surgeons work closely with radiologists.1,2 Rubin and Yoshimura3 demonstrated fewer mammographic changes in fat-grafted breasts compared with the breasts of breast reduction patients when independent, blinded radiologists read postoperative mammograms. Rigotti et al.4 demonstrated no difference in cancer recurrence rates in fat-grafted reconstructions compared with non– fat-grafted reconstructions following mastectomy. Following the logic of Dr. Wang et al. and the evidence demonstrated by Drs. Yoshimura and Rubin, breast reduction procedures should also be stopped immediately. Evidence from the radiologic literature supports the general concept that post–fat-grafted breast findings, such as calcifications and fat necrosis, can be distinguished from the malignant signs of irregularly shaped, high-opacity microcalcifications when supplemental imaging modalities are considered. Dynamic contrast-enhanced magnetic resonance imaging,5 ultrasound and computed tomography,6 computer-aided diagnosis,7 and finally digital magnification mammography8 have all been described in the radiologic literature as achieving such a distinction. It is unclear from the methods described in Wang et al.’s article exactly what type of mammography was performed and how the results were read. The term “digitized mammographic films,” used by Wang et al., implies that plain screen film mammograms were initially imaged and later digitized. The quality of digitized screen film mammograms is only as good as the quality of the original mammogram, and it is common industry knowledge that screen film mammograms are inferior to direct digital mammograms.9 Although fat grafting to the breasts is a relatively new technique for surgeons, fat-grafted breasts represent a new clinical situation for radiologists, who must develop a new set of standards and modalities for their proper reading. History demonstrates the need for additional imaging of breasts when plastic surgeons perform breast surgery. Modifications in mammography technique10 evolved after the advent of breast augmentation using prosthetic implants. Recently, the U.S. Food and Drug Administration mandated “postapproval study” surveillance of implants using breast magnetic resonance imaging.11 Such additional imaging modalities are not unfamiliar to plastic surgeons. It seems like a reasonable approach, therefore, to develop imaging standards that aim to separate benign from malignant calcifications in fat-grafted breasts, rather than to abandon fat grafting to the breasts altogether, as suggested by Wang et al., who wrote, “the method should continue to be prohibited.”