ORIGINAL ARTICLE Journal of Breast Cancer J Breast Cancer 2009 March; 12(1): 54-9 DOI: 10.4048/jbc.2009.12.1.54 자가지방이식을통한유방확대술의부작용 이상달 엠디클리닉 Complications of Augmentation Mammaplasty with Autologous Fat Grafts Sangdal Lee MD Clinic, Seoul, Korea Purpose: Autolougous fat grafting to the breast for cosmetic enlargement remains controversial because the efficacy and the complications due to fat necrosis are unclear. Methods: Ten cases who underwent autologous fat grafting to the breast for enlargement and visited author s clinic from October 2006 to March 2008 were evaluated retrospectively. Mammography, ultrosonography, culture, cytology, operative findings and results were reviewed for each cases. Results: The study group consisted of 7 cases for additional augmentation mammaplasty, 1 case for breast abscess, 2 cases for breast examination. Two of 7 augmentation cases had multiple palpable masses. One of 2 cases for breast examination had fat grafts 20 months ago and have suffered from painful huge masses especially on exercise. One case with abscess had fat graft 4 months ago and have suffered from painful reddish swelling. On mammography of 9 cases except 1 breast abscess, malignancy could not be excluded in 2 cases because of bizarre forms of multiple microcalcifications. On ultrasonography of 8 cases, there were ill defined hypoechoic masses in 2 cases which needed additional cytology for rule out malignancy. There were implant puncture in all 2 cases with silicone implants, and in case with abscess, there were S. epidermidis in culture. Among 7 augmentation mammaplasty cases, removal of fat necrosis was performed simultaneously in 1 case with severely palpable masses but postoperative seroma formation and capsular contracture occurred. Conclusion: Autologous fat grafting for breast augmentation can make masses, abscess and microcalcifications on mammography due to fat necrosis which compromise breast cancer detection. Additional study is necessary to evaluate the efficacy of fat stem cell grafts as an alternative to traditional method. Key Words: Augmentation mammaplasty, Autologous fat graft 중심단어 : 유방확대술, 자가지방이식 서 자가지방이식술은 1893년 Neuber에의해처음소개된이후여러의사들에의해시행되었다.(1) 1950년대들어 Peer (2) 는유리지방이식술을소개하였고유방확대를위한시술은 Murray (3) 에의해진피지방이식술이, Watson (4) 에의해유리지방이식 책임저자 : 이상달 (MDbP205) 135-897 서울시강남구신사동 664-13, 엠디클리닉 Tel: 02-542-0081, Fax: 02-542-4443 E-mail: dahl65@hanmail.net 접수일 : 2008년7월 24일게재승인일 : 2008년12월18일 * 본논문의요지는 2008년춘계유방암학술대회개원의심포지엄에서발표되었음. 론 술이소개되며여러시도가있었으나보편화되지못하였다. 1980 년대지방흡입술이대중화되면서흡입된지방을이용한유리자가지방이식술이다시활기를띄었고 (5-8) 1990년대초실리콘유방보형물에대한안전성문제로사용이금지되면서유방확대목적으로의자가지방이식술은더욱관심을끌게되었다. 그러나여러가지합병증으로부정적인의견도만만치않았는데 (9-11) 지방괴사와석회화침착소견이가장중요하였다. 최근우리나라에서도간혹자가지방이식을통한유방확대술이시행되고있으나기존의합병증가능성에대한근본적인대책이없는상태에서부작용발생도적지않아유방확대술목적으로적합한방법인지를확인하기위해본연구를하였다. 54
Complications of Augmentation Mammaplasty with Autologous Fat Grafts 55 방법 2006년 10 월부터 2008년 3월까지타병원에서유방확대목적으로자가지방이식을받고엠디클리닉에내원한 10 예를대상으로후향적조사를하였다. 이중 7예는유방확대술을목적으로내원하였고 1예는심한유방농양을주소로, 그리고 2예는유방검진을주소로내원한경우였다. 이들에대해이학적소견, 유방촬영술및초음파검사, 균배양검사등을시행하였고보형물삽입을통한유방확대술을시행받은 7예와농양에대한치료를받은 1예에대해수술소견및수술후경과를관찰하였다. 결과 시행한유방촬영상 6예에서는석회화침착소견을보였는데이중 2예에서악성과의감별이어려운소견을보였다 (Figure 2). 초음파검사를시행한 8예중 7예에서유방실질내에다발성낭종이관찰되었는데 2예의경우악성과의감별이어려운불규칙한경계를가진저에코성종양도포함되어세침흡인세포검사를시행하여지방괴사를확인하였다 (Figure 3A, B). 통증을동반한종괴가만져진예에서는대흉근내에각각우측 50 mm, 좌측 15 mm의직경을가진내부가지저분한저에코성종양이관찰되었으며 (Figure 3C) 유방농양을주소로내원한예에서는보형물주변에액체고임이심하였다 (Figure 3D). 보형물천공으로내원한예에대해서는파손된실리콘보형물 연령별분포는 20 대 2예, 30 대 4예, 40 대 4예로평균연령은 37.7세였고지방주입을받고본원에내원하기까지의기간은 1일에서 20 개월까지였다. 유방확대술을위해내원한 7예중 1예는 17 년전실리콘유방확대술을받았으나처짐개선을위해내원전날지방주입을받다가실리콘보형물이천공되어내원한경우였고, 이학적검사상 2예에서는양쪽유방에다발성의불규칙하고단단한종괴가만져졌다. 유방농양을주소로내원한 1예는 15 년전실리콘유방확대술을받았으나처짐개선을위해 4개월전지방주입술을받은후발열을동반한유방의발적, 부종, 압통을주소로내원하였다 (Figure 1). 유방검진을위해내원한 2예중 1예는통증을동반한유방종괴를호소하였는데내원 20 개월유방에지방주입을받은경우였다. 유방농양 1예를제외한 9예에대해 Figure 1. Breast abscess after fat injection. The arrow indicates reddish swelling. Figure 2. Mammographic findings. The pattern of microcalcifications is similar to malignancy.
56 Sangdal Lee A B C D Figure 3. Ultrasonographic findings. (A, B) The ill-defined, microlobulating hypoechoic mass looks like malingnant tumor. (C) The arrow shows a huge heteroechogenic mass in pectoralis major muscle. (D) The arrow shows a peri-implant hypoechoic density in cavity. Figure 4. Punctured silicone implant with gel leakage. Figure 5. Punctured contaminated implants and necrotic debris. 과피막을완전제거하고코히시브겔보형물로유방확대재수술을시행하였고 (Figure 4). 유방농양으로내원한예에대해서는절개및배농술을시행하였는데수술소견상실리콘보형물은다발성으로손상되어있었고내용물도심하게부패되어악취와함께피막내에농양으로가득차있었다 (Figure 5). 농양에대한균배양검사상 Staphyllococcus epidermidis가검출되어수 술후 6주간의추가적인치료가필요하였다. 유방확대술을시행한나머지 6예중다발성종괴가심하게만져진 1예에대해수술중대흉근하방으로접근하여지방괴사조직제거술을시행하였으나 (Figure 6) 모두제거하진못하였고수술후반복적인지방삼출액과함께구형구축현상이발생하여 6개월경과후피막제거술을시행하였다. 종괴가만져진다른 1예에서도유방확대술후경
Complications of Augmentation Mammaplasty with Autologous Fat Grafts 57 Table 1. Clinical features of cases Case Age Interval (month) History MMG US Operation Result 1 23 8 Mass/for aug Normal Multi cyst Aug Cap 2 28 5 For aug Cal Multi cyst Aug Good 3 31 12 For aug Cal Multi cyst Aug Good 4 36 7 Mass/for aug Cal Multi cyst Aug/ex Cap 5 37 12 Check up Cal 6 39 1 day Puncture/for aug Normal Nc Aug (re) Good 7 40 20 Painful mass Cal Huge mass 8 45 12 For aug Normal Aug Good 9 49 8 For aug Cal Multi cyst Aug Good 10 49 4 Painful swelling Abscess Culture (+), I/D MMG=mammography; US=ultrasonography; Aug=augmentation mammaplasty; Cal=calcification on mammography; Aug(re)=reoperation augmentation after previous implants removal; Cap=capsular contracture; Culture(+)=positive for Staphyllococus Epidermidis; I/D=incision and drainage; ex=excision of mass. Figure 6. Removed necrotic fat. 도의구형구축현상이발생하였다 (Table 1). 고찰지방흡입술의보편화로채취된지방을다시필요한부분에이식하는시술은 1980년대이후흔히시행되고있지만그효과는지방채취과정, 주입양, 주입부위등에따라다양하다. 지방조직은쉽게얻을수있고, 쉽게모양을다듬을수있으며더구나자가조직을이용하기때문에거부반응이나알레르기반응도희박하다는장점으로인해지방이식술의시술범위는점차확대되어왔다. 주로얼굴에미용효과를위해시술되었으며신체의결손부위의재건에대한활용방안도활발히논의되어왔다.(12,13) 이시술로인 한합병증으로부종, 혈종, 염증, 육아종형성, 낭종형성, 섬유화현상, 크기감소등이있을수있는데 (14-16) 합병증발병에영향을끼치는주된요인은혈액순환의정도이다.(17) 따라서혈액순환이비교적풍부한얼굴에서는효과적이며논란의여지도적지만혈액순환이빈약한유방조직에의시술은부정적인견해가많다.(8,9,11,18) 1950년 Peer (19) 는지방이식결과를현미경으로관찰한결과이식후 4일째가되면퇴행성변화가오는것을발견하였다. 2002 년 Langer 등 (17) 은이식된유리지방의생존에대한연구를하였는데 25 mm 3 크기의지방세포는 3일이면중앙부까지신생혈관이나타나는것을확인하였고경계부에비해중앙부의신생혈관생성은느리게진행되는것을발견하였다. Shakhov (20) 는이러한연구결과를토대로다량의지방이주입되었을때경계부위의생활력은유지되지만중앙부에는괴사가일어나게된다고설명하였다. Yamaguchi 등 (21) 도빠른신생혈관생성이이식지방세포에영양공급과혈관내피세포와지방세포간의상호혈관작용에중요하다고하였다. 유방의경우크기증대를목적으로하기때문에다량의지방이주입될수밖에없다. 유방실질의경우혈액순환이상대적으로빈약한조직이기때문에이식된지방의괴사율은높을수밖에없는데다량의지방이식술은혈관신생을지연시켜이를가중시킬수있다. 이에대한해결책으로대흉근주변에대한지방주입을들수있다. Karacaoglu 등 (22) 은근육의위와아래그리고피하조직의세군데에각각지방을주입한결과근육위에주입한경우가장생존율이높다고하였다. 유방의경우에도대흉근상방, 즉유선하부위에지방주입을함으로써생존율을높이는시도를할수있다. 하지만이역시다량의지방을괴사로부터보호하기엔충분하지않은방법으로본연구의증례에서도대흉근상방및내에주입된지방의괴사로인해오히려통증을동반한유방종괴가발생한예가있다. 대흉근이포함된부위의지방괴사
58 Sangdal Lee 는근육의운동성에따른통증까지도동반될수있기때문에적절한해결책이될수는없음을알수있다. 1987년미국성형외과학회에서는유방에대한자가지방이식이유방암검진의장애가될수있어시행을금지해야한다는견해를밝혔다. 그러나이에대한논란이끊이지않는가운데유방촬영술이나초음파검사로악성과구분이된다는의견도있지만 (23,24) 대부분지방괴사로인한석회화침착이나가성낭종형성등이불필요한조직검사를유발하는원인이되기도하여적합한시술은아니라고하였다.(14,25,26) 본연구의증례들에서도유방촬영술과초음파검사만으로는악성과의감별이확실하지않아세침흡인세포검사가필요한예들이있었다. Zocchi와 Zuliani (27) 는 181 예에대해지방이식술을시행하였는데피하조직과유선하부위에이중으로주입함으로써생존율을 40-70% 까지높였고유방암과의감별도용이하였지만지방이식술이완전히유방보형물을대치하기에는부적합하며보형물사용과함께보조적인방법으로만가능하다고하였다. 본증례에포함된 2예의경우기존보형물이있는상태에서처짐개선을위해부분적인지방주입이보형물천공을초래한경우여서이역시기술적인문제가있음을보여준다. 한편, 지방이식방법의개선을통해이식지방세포의생존율을높이려는시도는지방이식술의긍정적인가능성을보여주기도한다. 2002년 Zuk 등 (28) 은지방조직에서중복성줄기세포 (multipotent stem cell) 를추출할수있고이는골, 지방, 근육, 연골등으로의분화가가능하다고하였다. 2008년 Yoshmura 등 (29) 은지방줄기세포를유리지방과혼합하여주입함으로써지방세포의생존율을높일수있다고보고하였다. 따라서여러연구자들 (22,28,29) 의연구결과를토대로대흉근상방에지방줄기세포를정확히주입한다면지방세포의생존율을더욱높일수있을것이다. 그러나이미보형물을통한유방확대술을시행한경우에는기술적으로지방의대흉근상방주입이어렵고보형물손상가능성이매우크기때문에지방주입술은시행하지않는것이좋을듯하며지방이식술은비록자신의세포를이식함으로써거부반응은없다하지만이식세포의괴사율이높은만큼이에대한합병증가능성을충분히고려하여시술에임해야하고시술후세심한유방암검진이필요하다는점을충분히고려해야할것이다. 결론유방에대한자가지방이식술은지방괴사로인한혹이나염증을유발할수있고유방촬영상석회화침착소견을만들어유방암검진을방해할수있어시술후보다세심한유방암검진이필요하다. 지방괴사와이로인한합병증을줄이기위해서는지방줄 기세포를이용한자가지방이식술의연구도필요할것으로사료된다. 참고문헌 1. Neuber GA. Fettransplantation. Chir Kongr Verhandl Deutsche Gesellschaft fur Chirurgie 1893;22:66. cited from Langer S, Sinitsina I, Biberthaler P, Krombach F, Messmer K. Revascularization of transplanted adipose tissue: a study in the dorsal skinfold chamber of hamsters. Ann Plast Surg 2002;48:53-9. 2. Peer LA. Transplantation of fat. In: Peer LA, editor. Transplantation of tissues. Baltimore: William and Wilkins Co.; 1959. p.165. 3. Murray DS. Breast augmentation with gluteal dermofat grafts: a 5-10 year follow up. Br J Plast Surg 1976;29:1-4. 4. Watson J. Some observations on free fat grafts: with reference to their use in mammaplasty. Br J Plast Surg 1959;12:263-74. 5. Bircoll M, Novack BH. Autologous fat transplantation employing liposuction techniques. Ann Plast Surg 1987;18:327-9. 6. Bircoll M. Autologous fat transplantation to the breast. Plast Reconstr Surg 1988;82:361-2. 7. Fox BS. Autologous fat injection and breast augmentation. Med J Aust 1988;149:284-6. 8. Matsudo PK, Toledo LS. Experience of injected fat grafting. Aesthetic Plast Surg 1988;12:35-8. 9. Pohl P, Uebel CO. Complications with homologous fat grafts in breast augmentation surgery. Aesthetic Plast Surg 1985;9:87-9. 10. Hartrampf CR Jr, Bennett GJ. Autologous fat from liposuction for breast augmentation. Plast Reconstr Surg 1987;80:646. 11. Dixon PL. Autologous fat injection and breast augmentation. Med J Aust 1988;148:537. 12. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour deformities in the reconstructed breast. Plast Reconstr Surg 2005; 116:1300-5. 13. Missana MC, Laurent I, Barreau L, Balleyguier C. Autologous fat transfer in reconstructive breast surgery: indications, technique and result. Eur J Surg Oncol 2007;33:685-90. 14. Castello JR, BarrosJ, Vazquez R. Giant liponecrotic pseudocyst after breast augmentation by fat injection. Plast Reconstr Surg 1999;103: 291-3. 15. Chajchir A, Benzaquen I. Fat-grafting injection for soft tissue augmentation. Plast Reconstr Surg 1989;84:921-34. 16. Niechajev I, Sevcuk O. Long-term results of fat transplantation: cli-
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