Liponecrotic Nodules After Autologous Fat Transfer For Breast Augmentation

Case history: A 53-year old female patient presents with palpable breast masses, right greater than left.

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Figure 1: Right Breast

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Figure 2: Left Breast

Findings:

Figure 1 – Longitudinal and transverse grayscale ultrasound images of the right breast at the 1:00 position in the region of the palpable abnormality. Images demonstrate multiple subcentimeter hypoechoic nodules. Lesions are homogenous and very well defined with smooth margins. The largest nodule measuring approximately 1.5 cm contains a thin internal septation. Although not shown, color Doppler images demonstrated a lack of internal vascular flow within all lesions.

Figure 2 - Longitudinal and transverse grayscale ultrasound images of the left breast at the 12:00 position in the region of the palpable abnormality. Images demonstrate several very small hypoechoic nodules. Lesions are also homogenous and very well defined with smooth margins. Although not shown, color Doppler images demonstrated a lack of internal vascular flow within these lesions as well.

Diagnosis: A 53-year-old female patient with biopsy proven lobular carcinoma in situ in the right breast and biopsy proven invasive ductal carcinoma in the left breast underwent bilateral mastectomies with immediate reconstruction with silicone implants in November 2011. Due to postoperative assymetry, the patient underwent second-stage reconstruction and bilateral lipofilling of the breasts right greater than left six months later. In November 2012, she presented with new bilateral breast lumps right greater than left.

Ultrasound findings of multiple well defined, smoothly marginated, homogenously hypoechoic breast masses in a patient with a history of autologous fat transfer are virtually diagnostic for oil cysts.

Conclusion: When detectable on mammography, areas of lipoinjection typically have a rounded radiolucent appearance. Occasionally fat necrosis can give rise to microcalcifications which are usually classified as dystrophic and therefore easily distinguishable from malignant calcifications. At ultrasound, oil cysts from fat injection typically appear as ovoid hypoechoic lesions which lack internal vascular flow. Areas of lipoinjection that have undergone fat necrosis usually demonstrate a hetereogenous echotexture with complex features and may appear mass-like.

Recent literature suggests that oil cysts are best characterized using ultrasound. For difficult cases where the differential includes both fat necrosis and cancer, MRI is probably the most sensitive method for differentiation.

The transfer of autologous fat to diminish breast asymmetries in patients who have undergone breast reconstruction is a practice that is becoming more common. Unfortunately the development of fat necrosis and/or oil cyst formation after this procedure occurs frequently. In patients with a history of breast cancer, the presence of a new breast nodule(s) can be a stressful experience. Surgeons performing this procedure must discuss the potential of liponecrotic pseudocyst formation with their patients.

Edward Harter, MD, and Erini Makariou, MDGeorgetown University Hospital

References:
Chan CW, McCulley SJ, Macmillan RD. Autologous fat transfer – a review of the literature with a focus on breast cancer surgery. Journal Plastic Reconstruction Aesthetic Surgery. December 2008. 61(12): 1438-48.
Costantini M, Cipriani A, Belli P, Bufi E, Fubelli R, Visconti G, Salgarello M, Bonomo L. Radiological findings in mammary autologous fat injections: A multi-technique evaluation. Clinical Radiology. June 2012.
Kim H, Yang EJ, Bang SI. Bilateral liponecrotic pseudocysts after breast augmentation by fat injection: a case report. Aesthetic Plastic Surgery. April 2012. 36(2): 359-62.
Veber M, Tourasse C, Toussoun G, Moutran M, Mojallal A, Delay E. Radiographic findings after breast augmentation by autologous fat transfer. Plastic Reconstruction Surgery. March 2011. 127(3): 1289-99.