Fat Capital

Abstract

Within the domain of breast reconstruction, abject fat has become a form of biovalue to be harnessed, harvested, and remediated through fat transfer, fat grafting, the therapeutic use of fat stem cells, and fat banking. Each of these technologies deploys fat as capital and promises to return corporeal wholeness following breast cancer surgery. This paper explores the supposed endless malleability of fat and the Promethean dream it represents. In the context of these technologies, the paper asks under what conditions can fat become biovalue; what new corporeal economies are created through the labor of fat; how is this form of biovalue inextricable from the vast circuitry of the breast cancer industry; and how do broader patterns of social dispossession delimit who has access to this dream? It becomes evident that fat gets to be revalued and remediated by women already privileged within circuits of capital, demarcations along lines of race, and notions of normative embodiment. Ultimately, it is the ideal neoliberal subject – one who is ‘able’ to assume responsibility for her own health – that is the inheritor of this dream.

KEYWORDS:

• biotechnology
• biovalue
• capital
• medicine
• gender

Within Western epistemological systems and material relations, fatness is understood as a bodily deficiency, and ‘fat bodies are constructed (and discriminated against) as being unhealthy, ugly, and “out of place”’ (Colls 2007, p. 358). The very material substance of fat is defined as abject and, accordingly, positioned as that which must be expelled from the body (Kent 2000, p. 138) – precisely because it is seen as surplus and negative waste. Importantly, however, fat has no ontological status. Rather, the way fat signifies – the meaning it accrues and the status it holds – depends on the ‘domain’ within which it comes to be known and operates.

This paper is concerned with exploring medico-technological deployments of fat in the domain of breast reconstruction following breast cancer surgery, and with considering the alternative material economies of the body that are enabled and produced through such deployments. The domain of breast reconstruction offers a range of salient examples of the reordering, transformation, operationalization, and instrumentalization of fat, for in this domain it becomes evident that certain forms of fat are considered desirable and good: indeed, fat represents a form of corporeal capital. Adipose tissue – fat – is one of the primary components of breast morphology, which is a key corporeal form in the signification of femininity (Young 1992). When this tissue is either partially or fully removed through breast cancer surgery, the notion of corporeal integrity is threatened and, in turn, gendered subjectivity is potentially destabilized. In the context of this form of loss – and threat to integrity – breast reconstruction technologies labor to ‘return’ or ‘repair’ the body to its prior form through recrafting breasted morphology.¹

That fat has become central to this endeavor highlights that it operates in/as what Catherine Waldby and Robert Mitchell have called a ‘tissue economy’ (2006, p. 31) – a term that points to the fact that tissue is productive and is able to be ordered or valued in various ways, particularly with the emergence of new biomedical technologies. Within tissue economies, the value of human tissue is adjudicated and organized, and tissue that may have previously been designated as corporeal waste can be reordered as ‘value’. This is precisely what occurs in many contemporary breast reconstruction technologies, in that what is generally taken to be an abject tissue to be wasted – expelled from the body – undergoes a change in status to become a tangible form of what Catherine Waldby has named biovalue. For Waldby, biovalue ‘refers to the yield of vitality produced by the biotechnical reformulation of living processes’ (2002, p. 310), while Nikolas Rose uses the term to refer to ‘the value extracted from the vital properties of living processes’ (2007, p. 32). Fat is distinct from other forms of excess body material, such as ova, sperm, and embryos, precisely because where it is deemed excessive, it is pathologized. It is also distinct, however, from other forms of pathologized bodily waste (such as feces, urine, and pus) because of its potential utility in a therapeutic context.² Fat becomes biovalue in breast reconstruction because its very vitality – its live-ness, malleability, and capacity – can be harnessed and redeployed, and this takes place ‘in order to promise a return to corporeal wholeness’ after breast cancer surgery.

By invoking wholeness, I point to the post-Enlightenment paradigm of the idealized subject, who is seen to be invulnerable, closed, and complete, and whose body functions in accordance with normative prescriptions. In such an understanding, the body is ideally unitary, defensible, and controlled, with all body parts in their supposed ‘proper’ anatomical places (Shildrick 1997; Cohen 2009). Importantly, the ‘whole’ body is marked by a sense of corporeal consonance or seamlessness which, according to Drew Leder (1990), enables it to essentially be taken for granted by (and thus ‘absent’ to) the subject. The surgery that often accompanies a breast cancer diagnosis and, indeed, the diagnosis of breast cancer itself, evacuates the possibility of experiencing the body as whole, defensible, seamless, and absent. Yet, breast reconstruction can ostensibly recuperate the corporeal lack represented through the loss of a body part, such as a portion, quadrant, or entire breast and make the body whole again. The organizing logic of breast reconstruction thus differs from nontherapeutic breast augmentation: augmentation is focused on ‘enhancement’ of the body in line with idealized feminine corporeality, while reconstruction is predicated on attending to ‘loss’; alongside this point, unlike augmentation, reconstruction might function as a way for the subject to assert some kind of control in the face of a threat to bodily integrity and life. In the context of such loss and in the service of the promise of ‘wholeness’, fat is put to work. Thus, fat becomes an enabling bioresource: it is reanimated and remediated, it accrues therapeutic utility, and, as such, its status shifts from valueless ‘garbage’ to value-laden ‘gold’ (Waldby and Mitchell 2006, p. 114). Importantly, as Waldby and Mitchell note in their analysis of tissue economies, waste and value should not be understood as oppositional categories, nor should the movement from understanding a certain tissue as waste to understanding it as valuable be seen as a simple reversal of status. Rather, it is only because a tissue is designated as waste or surplus that it can be redeployed and, hence, epistemologically revalued ‘in another context’: value is facilitated by the very fact that the tissue is identified as waste. When it comes to breast reconstruction, then, the fat that is usually deemed abject is always already a latent form of value.

In what follows, I consider how fat is harnessed, harvested, and remediated in several contemporary breast reconstruction technologies: fat transfer, fat grafting, fat stem cell technologies, and fat banking. My interest is not directed toward women's individual, subjective, and material experiences of these technologies.³ Rather, I am more concerned with exploring the specifics of the technologies themselves in order to apprehend the value fat is accorded, the labor it performs (how it is put to work), and the intricacies of the technicities that animate this tissue. Two points become clear through such an analysis. First, by foregrounding the workings of these technologies, we see that a return to normative embodiment is vexed and that using fat in breast reconstruction might compel particular contingent and emergent materialities that ultimately undercut the promise of wholeness. Second, in looking at the particularities of fat technologies, it becomes evident that the reordering of fat is inextricable from larger circuits of capital and patterns of inequity in the broader political economy.

The breast reconstruction technologies that I list above instrumentalize fat in divergent ways and operate on two distinct registers. The first register operates through the ‘redistribution’ of fat. One key form of reconstruction that redistributes existing fat from the body is the fat transfer technology known as autologous, or living-tissue, reconstruction. This might be thought about as a form of ‘mammary organics’, as the technology involves using existing fat deposits from one part of the body in order to relocate them to another part (the chest) to craft new and organic breasts. Autologous breast reconstruction is by no means a new invention, however. For over a century, surgeons have used patients' own fat, muscle, and skin to enlarge and reshape breasts. The first documented breast reconstruction using such methods was performed in 1895 by the German physician, Vincent Czerny, who transplanted a lipoma (a benign tumor comprising fat tissue) from the lumbar region to reconstruct a breast (Del Vecchio and Fichadia 2012).⁴ In recent years, autologous reconstruction has become a primary form of breast reconstruction and is heralded as providing a more natural/whole esthetic result than reconstruction using alloplastic implants.

There are several forms of autologous breast reconstruction, the most common being the Pedicled TRAM (transverse rectus abdominis) flap procedure, which uses fat, muscle, and skin flap from between the belly button and pubic area that is tunneled through the body to make a breast. To be a candidate for this form of reconstruction, a woman must have adequate (and what is usually thought of as excessive) lower abdominal fat tissue to create one or both breasts. Other procedures using harvested fat include the DIEP (deep inferior epigastric artery perforator) procedure (using an artery from the upper abdominal region to maintain the harvested abdominal fat), the SIEA (superficial interior epigastric artery) procedure (using an artery from the lower abdomen), and the Free TRAM Flap (where fat tissue is used to create a breast shape without having to be tunneled under the skin). When there is insufficient fat on the body, other procedures are used and other parts of the body harvested: the TUG (transverse upper gracilis) flap utilizes the fatty tissue of the upper-inner thigh, the GAP (gluteal artery perforator) procedure takes fat from the buttocks, and the LAT (latissimus dorsi) procedure uses fat, muscle, and skin from the back to make a reconstructed breast.⁵

Each of these procedures instrumentalizes fat – along with skin and muscle – to model the norms of the breast. While reconstruction using silicone implants has the same end-goal, using fat is generally considered more successful, in that an autologous breast will visually appear and feel more ‘natural’ than those created through the use of implants: they become fully integrated into the body and respond to changes in body weight, and they enable the crafting of breast ptosis (fall or drooping) that is not achievable with implants. Yet, while this form of reconstruction might enable the fashioning of a certain level of corporeal normativity, there are a range of complications that challenge the possibility of a return to ‘wholeness’. For instance, the tissue flap may turn necrotic and fail (resulting in the need to remove the entire flap), the procedures result in considerable scarring to the donor sites, and the donor site injury cost is considerable – often leading to abdominal bulge and hernia or muscle weakness and ongoing nerve sensitivity in those areas (Nahabedian et al. 2002, p. 466). And while normative female embodiment might be signified at the level of appearance (particularly when clothed), this social ontology is undercut by the material ontology that it is dismantled fat from the stomach, upper thigh, buttocks, and back redistributed and ‘made’ breast.

A second form of breast reconstruction that instrumentalizes fat through redistribution is the range of procedures that are collectively referred to as fat grafting. In these procedures, fat is harvested through lipoaspiration (from the abdomen, hips, thighs, buttocks, or trochantal areas), treated through saline washing/centrifugation and refinement, and then transferred back into the body. This biocompatible filler is used in several ways: to supplement a primary reconstruction using implants (softening the edges around an implant and lending soft tissue coverage), to correct contour deformity (related to an implant or to supplement flap reconstruction), or to improve skin quality following radiotherapy (Coleman and Saboeiro 2007; Spear, Wilson, and Lockwood 2005). Fat grafting has also been used as a means to entirely rebuild a woman's breasts following a mastectomy and radiation. In a recent Italian case, for instance, lipoaspirated fat was injected into a patient over a period of eight months, with the fat acting as both the expander (of the radiated skin) and the filler (of that skin) (Panettiere et al. 2011). Another innovation known as the BRAVA technique uses fat grafting in conjunction with an external tissue expander (a bra-like structure that is worn for several weeks before and after fat grafting) to enlarge the breasts through mechanical tension (Khouri et al. 2000).⁶ In all cases, the aim of fat grafting is to have the fat become vascularized after it has been injected in order to ensure its survival, to return breasted materiality, and, through this, to reinstate a sense of corporeal wholeness. This aim is troubled, however, due to the fact that injected fat can be reabsorbed by the body (and breast volume lost over time) or injected fat can become necrotic. Additionally, these procedures can result in infection, cellulitis, calcifications, and oil/fat cysts, and many plastic surgeons have questioned the efficacy and ethics of fat grafting, because some of these side effects – such as calcification in the breast – can interfere with subsequent breast cancer detection.

Both fat transfer and fat grafting can be said to be structural technologies, in that they labor to return the very structure of the breast. Such structural redistribution of fat is marked by several key factors. First, the economy at work in such procedures involves determining ‘where’ potential excess or surplus fat is on the body, ‘how much’ there is (what is expendable), and how it will be ‘moved’. Second, the focus of these technologies is on the ‘transplantation’ of given form: the existing form of flesh, muscle, and fat is transplanted and molded into a predetermined breast form. Here, fat is that which gives form (it is morphological), but that ‘form is imposed’, precisely because it is transferred into the body, albeit from another part of the body. As Melinda Cooper has noted in regards to transplant surgeries more generally, ‘active form [is] imposed on formless matter’ (2008, p. 113). Or, as Sharon Begley (2010, n.p.) has phrased it:

the doctor squeezes, and smooshes, and moves tissue to fill in divots and missing quadrants and, with luck, turns what might have been reduced to an A cup during a cancer operation [or removed completely] in a match for the B or C on the healthy side.

Third, and related to the previous point, the body is viewed in a mechanistic sense in these technologies, with various tissues seen as interchangeable. This is not a point-to-point substitution, obviously, because what is transferred is not breast but fat tissue ‘made to become’ breast: as such, one part of the body becomes the mimetic equivalent of another and effectively materializes breasted enfleshment. Lastly, the overriding imperative of these technologies is to achieve tissue survival, integration, and stasis and, as a consequence, the energies of the body are directed toward fighting possible infection or tissue rejection in order to maintain the integrity of the transplant over time (Cooper 2008, p. 113). Ultimately, however, these technologies labor to return a sense of corporeal wholeness and that goal is delimited. On the one hand, it becomes evident that achieving normative embodiment is an enterprise fraught by complications and that rather than regaining a sense of bodily seamlessness or ‘arriving’ at a point of bodily wholeness, the subject may instead experience the body as transitional and contingent – due to the failures that accompany such procedures or the material traces these technologies leave. On the other hand, the teleological end-goal of achieving corporeal wholeness is paradoxical in that the body can only be (supposedly) made ‘whole’ again through disaggregating it.

In addition to being deployed according to the logic of redistribution, fat operates on a second register in the tissue economy of breast reconstruction, where it is instrumentalized according to the logics of morphogenesis. In this register, technologies, techniques, and technicities put fat to work by ‘growing’ it – through autogenic processes – in order to create new breasted materialities. These technologies are significant because they represent efforts to initiate and harness the capacities of morphogenesis itself and, through this, extend and refine the customization of matter – a pursuit that is only enabled due to the malleability of fat.

One way that the morphogenesis of fat is used in the process of breast reconstruction is through women's practice of growing surplus fat in order for it to be harvested at a later point in autologous reconstruction. This might occur, for instance, if a woman does not have adequate fat reserves to make two full C-cup breasts, so puts on weight over a relatively short period of time in order to achieve the required amount. In other instances, women will generate more fat in order to have extra for lipofilling procedures (if large quantities are needed and they have ‘low’ reserves). On one particular webforum related to breast reconstruction, for instance, a participant talked of being instructed by her plastic surgeon to put on twenty pounds so that he would have enough tissue to work with for her DIEP procedure. Another referred to her reconstructed breasts as ‘mini-muffins’ that rose from her specially grown ‘muffin top’. What is particular about such efforts is that women strategically and tactically enhance the bioresource of fat in order to yield a greater return and, thus, maximize the possibility of regaining a sense of corporeal wholeness. Such practices are risky, however, because fat increases the estrogen levels in the body and, particularly for women diagnosed with estrogen-positive breast cancer, increased estrogen elevates the chances of the cancer returning or metastasizing. One oncologic study found, for example, that doubling fat intake, from 20% to 40%, was associated with a 15% increase in breast cancer risk.⁷ In light of such statistics, the activity of fat autogenesis can foster a growth that kills. Aside from this tangible threat to corporeal integrity, it is important to note that this particular process of fat autogenesis is ultimately recuperated back into the first register of the tissue economy of breast reconstruction that I outlined above, in that this grown fat is deployed in forms of reconstruction governed by the logic of redistribution. Here again, fat tissue represents a form of limit (and limit of form) and will be subjected to structural technologies that mould the harvested tissue into predetermined forms.

The relatively recent discovery of stem cells in fat tissue has, however, altered the limitation – and limit of form – previously associated with fat and has been a ‘eureka’ moment in bioprospecting and biotechnological developments (Begley 2010; Zuk 2013). Indeed, new possibilities for embodiment and life itself have been found ‘hidden in a pair of love handles’ (Begley 2010, no page). As University of California, Los Angeles pediatric plastic surgeon, Marc Hedrick, has noted, ‘fat is not the tissue we once thought. For too long it was seen as something to be removed and tossed away [following most forms of lipoaspiration].... We weren't seeing its potential. We now know that it's not just spare tissue...’ (cited in Terranella, n.d.). What is so promising about this discovery is that fat-derived stem cells – what are known as adipose-derived stem cells or ASCs – can be used within tissue engineering and regenerative medicine to regenerate injured parts of the body and, thus, enable corporeal renewal. Thus, with the identification of stem cells in fat, the surplus or residual becomes regenerative and emergent, thereby expanding the material and biotechnological possibilities and capacities of fat and exponentially increasing its ‘value’.

ASCs are what are known as adult stem cells. Both embryonic stem cells and adult stem cells renew themselves in a process of self-renewal or morphogenesis. However, while embryonic stem cells are pluripotent, meaning that they are ‘blank’ or undifferentiated cells that hold the potential to give rise to any type of cell, adult stem cells have a specific physiological function – to replenish the cells in their home tissues as needed. Adult stem cells are multipotent: these cells can give rise to different kinds of cells in their home tissues through entering normal differentiation pathways, but they do not normally generate cell types outside of their particular tissues or cell lineages. Despite this restricted developmental potential, adult stem cells can be manipulated ‘in vitro’ to differentiate into different types of cells, including cells of different germ origin, and ‘in vivo’ the same changes can be seen when these stem cells are transplanted into a tissue environment other than their tissue-of-origin.

Adult stem cells have been identified in many organs and tissues, including brain, bone marrow, peripheral blood, blood vessels, skeletal muscle, skin, teeth, heart, gut, liver, ovarian epithelium, and testis (Carlson 2007, p. 244). And, while the stem cells found in bone marrow have been considered the gold standard of adult stem cells, they are difficult to source and such sourcing is achieved only through complicated and painful procedures. Finding stem cells in fat has then altered the terrain of stem cell science, and ASC technologies/therapeutics are becoming increasingly common in applied regenerative medicine (Zuk 2013). The reasons for this are three-fold: harvesting stem cells from fat circumvents the ethical minefield associated with using stem cells from embryos – because fat, unlike the embryo, is seen as inconsequential tissue; it is easy to source – liposuction is a relatively common and uncomplicated procedure, and over 400,000 liposuctions are conducted per year in the US alone, with each yielding between 100 mL to >3L (Gimble, Katz, and Bunnell 2007, p. 1249); and, beyond being expendable, nearly everyone has some fat that they can spare. Moreover, fat has been identified as the richest source of adult stem cells (Zuk et al. 2002; Fraser et al. 2006) and these cells have been found to not only generate adipose tissue but also successfully differentiate – through inducing processes – into bone, cartilage, muscle, skin, and nerves (Zuk 2013).⁸

ASCs have specifically been imagined as ‘breast-making gold’ (Begley 2010), and breast reconstruction using ASC therapy has become the first major form of applied fat stem cell therapy. That ASC therapeutics developed in the context of breast reconstruction may be due to the fact that breasts are seen as inconsequential to the laboring body; that is, breasts are not required to ‘work’ in order for the individual's body to survive.⁹ It is considerably easier and more strategic to then clear regulatory hurdles through conducting stem cell research in relation to breasts rather than other tissue or organs. But despite the fact that breasts are seen as relatively inconsequential within the general taxonomy of corporeal significance, ASC therapy represents an important way through which individuals might reimagine and materialize the body after breast cancer surgery – by deploying fat to produce an ‘emergent’ breasted materiality; that is, a breast that arises or emerges from the genesis of cells and the interaction of these cells within the biological organism of the human body.

Two companies have been significant in the development of ASC therapy in relation to breast reconstruction. The first is the San Diego–based biotech company, Cytori Therapeutics®, which has developed what it calls the RESTORE procedure.¹⁰ This procedure involves harvesting fat through liposuction, injecting this fat into what they call the Celution system – a patented machine that processes the tissue, extracts the patient's regenerative cells, and concentrates them into a pellet. These concentrated stem cells are then combined with some of the liposuctioned fat cells to create a liquid suspension, which is then deposited back into the breast site, creating a biological mesh that is subsequently incorporated into preexisting tissue. The RESTORE procedure is heralded as being more successful than traditional fat grafts because the ASC-rich suspension increases the growth factor signaling at the interface between the newly grafted tissue and the adjacent vascularized tissue, improving overall incorporation (Pérez Cano et al. 2012). A second company pursuing ASC therapy for breast reconstruction is Neopec Pty Ltd, which is Australian based and funded by the Victorian State Government. Neopec – whose guiding motto is ‘natural. individual. forever.’ – aims to ‘entice a woman's own regenerative capacity to grow living fat as a substitute for breast reconstruction’.¹¹ The technique developed by the company involves implanting a biodegradable synthetic chamber into the mastectomy site, redirecting blood vessels from under the armpit into the chamber and injecting the chamber with stem cell–rich lipoaspirate, which will grow to fill the space of the chamber over a period of four to six months.¹²

Both of these morphogenic technologies endeavor to reimagine breasted materiality and enable a supposed return to normative embodiment in ways that are very distinct from redistributive technologies. At the most fundamental level, this distinction can be seen in the fact that, where redistributive technologies aim to ‘reconstruct’ the breast, morphogenic technologies ‘regenerate’: rather than imposing form or pursuing the substitution of form, morphogenic technologies are concerned with the genesis and animation of form itself. Thus, while redistributive technologies aim at tissue stasis and survival in order to ensure the successful integration of the fat transplant into the body, these new technologies using stem cells rely on processes of transformation and growth of tissue itself. Consequently, they alter the economy of the body: the labor or energy of the body is directed at the reproduction of cellular life (rather than fighting and survival) and, rather than being predicated on reproducing standardized norms (of the breast, embodiment, and life) as redistributive technologies do, morphogenic technologies regenerate the transformable – the emergent stem cell.¹³ Yet, it is this reliance of cellular growth and transformation that makes this technology risky. As Cooper has noted (2008, p. 125), cells might grow or proliferate ‘too’ well and, where the first signs of life can also mark the first sign of death, the excessive vitality of cells might result in the material emergence of cancer.

Despite this risk, ASC technologies have increased the value of fat because they offer the opportunity to extend and enhance the limits of the human, by helping the body rebuild – by regenerating corporeality. Such a possibility – and the autogolous economy in general – holds particular neoliberal appeal, due to the fact that it enables individuals to optimize the body and give what Waldby and Mitchell refer to as a ‘gift of self to self’ (2006, p. 56); by investing a part of their body in their own future and relying on their own corporeal resources for that future. This reliance on the self is part of a broader operation that Rose (2007, p. 25) names as ‘the ethic of active citizenship that has taken place in advanced liberal democracies’. Within this ethic, ‘the maximization of lifestyle, potential, health, and quality of life has become almost obligatory ... [and individuals are compelled to] adopt an active, informed, positive, and prudent relation to the future’ (Rose 2007, p. 25). Self-reliance and the maximization of life are particularly evident in the emergence and proliferation of ‘fat banks’, where individuals can have harvested surplus fat stored through cryopreservation. The premise of this banking is that stored fat can be reanimated at a later point for a range of therapeutic applications – such as repeated breast reconstruction revisions – or it can be kept (supposedly indefinitely) until ASC research is developed into future clinical practices. Fat banking is, then, a future-oriented storing of promise, a fact seen in the language deployed by the banks themselves. For example, American CryoStem refers to the fat banking service they provide as ‘bioinsurance’; BioLife Cell Bank calls on the individual to ‘Preserve your cells. Preserve yourself’; and a fat bank appropriately called Liquid Gold markets their facility through the slogan ‘invest/save/withdraw’. With fat banking, however, the promise and value of fat is spectacularly financialized showing, as Waldby and Mitchell note, that subjects are being called on to ‘pay good money to buy back ... [their] own bodily waste after it [has] ... been processed through the infrastructure of commodity capitalism’ (2006, p. 83). BioLife Cell Bank, as a case in point, offers two major banking ‘packages’ – a ‘fat (adipose) banking package’ and a ‘stem cell banking package’ – with pricing for processing and storing starting at around US$2000 per year.¹⁴

Fat is not only being banked and banked on for individual purposes, for it is anticipated that ASCs will provide the means through which to combat a range of diseases and thereby foster health at the level of the population. Cytori Therapeutics®, for instance, aims to introduce stem cell therapy using ASCs to the mass market, proposing that their therapy (which has predominantly focused on breast reconstruction) will ‘be the key to [treating] every ischemic disease’, in which tissues die for lack of blood supply (Begley 2010, no page, my emphasis). Their claim is that by increasing blood supply, stem cells found in fat will be able to enhance, heal, and rebuild a range of damaged tissues (such as those affected by heart attack or kidney injury) and treat conditions such as chronic heart disease and incontinence. Corporations are thus employing adipose tissue as a speculative asset and converting the (always potentially) latent corporeal capital of fat into economic capital, a fact that is perhaps most clearly evidenced by the explosion of stem cell clinics worldwide and the burgeoning of stem cell tourism. The National Stem Cell Foundation of Australia refers to such practices as a form of ‘cowboy culture’, in that biotech companies and biomedical practitioners are reaping huge financial profits from therapies that are currently often unregulated and unproven.¹⁵ In another permutation, ASC therapies have been imagined as a potential way to combat rising levels of obesity in the population, with the American Heart Foundation predicting that ‘future citizens may undergo liposuction to remove excess adipose tissue in “fat drives”’ (Gimble, Katz, and Bunnell 2007, p. 1249). In this incantation, fat banking is ostensibly imagined as a solution to the obesity epidemic.¹⁶

Based on this range of possible applications, and in a world full of this now-valuable tissue, fat seemingly represents the ultimate Promethean dream – for corporeal repair or renewal and for the pursuit of a ‘whole’ and ‘complete’ body. Yet, while the surgical and biotechnological capacities of fat are indeed promising, a range of contingencies that I have outlined clearly complicates its therapeutic use. Moreover, such promise cannot be divorced from the broader social environment in which these technologies operate and the wider political economy. In relation to breast cancer in particular, several additional factors then need to be kept in mind when considering this dream.

First, it becomes apparent that this dream is only for certain people. Taking the US as an example, the Promethean possibility and the teleological end-goal of realizing the (always-vexed) promise of corporeal wholeness is conditioned from the outset by racial disparities in breast cancer incidence rates, diagnosis, and survival. According to the US National Center for Health Statistics, in 2006, death rates from breast cancer among African-American women were 38% higher than among white women, and by 2009 this figure had risen to 41%. Latino women have a 20% higher mortality incidence related to breast cancer than white women, and the five-year relative survival rate for American Native Indian women is the lowest of any racial or ethnic group. Such discrepancies can be largely attributed to lower frequency of mammograms and early screening, lack of insurance and/or access to health care, and the ‘unequal receipt of prompt, high-quality treatment’.¹⁷ If health is unable to be divorced from patterns of structural racism and social and economic disenfranchisement, and minority women are dying at increased rates, then ‘wholeness’ is an always already a foreclosed dream for some. This dream is further delimited by the fact that even if women survive the disease, there are discrepancies in terms of options to access breast reconstruction technologies – and specifically those using fat. In 2009, significant predictors of immediate reconstruction in the US were white race and private insurance. Significant predictors of no reconstruction were diabetes, obesity, black race, and Medicaid (Shin 2013). When the average cost of reconstruction surgery (particularly autologous flap procedures) and affiliated costs runs in the area of $US50,000–$100,000 (without insurance), the potential to pursue ‘wholeness’ needs to be understood as a privilege enjoyed by a largely white, upper-middle class, insured, and corporeally viable population of women.¹⁸ Corporeal viability, here, is predicated on women having what is thought of as ‘acceptable’ levels of fat. Thus, while it might be tempting to assume that fat technologies rework how obesity is viewed, this is not the case. Obese women are usually ineligible for these surgeries, meaning that if a patient is deemed as being too fat (i.e., being biomedically defined as obese), fat can only-ever exist as waste. While this restriction – and designation of fat as ontologically waste – inarguably applies to a wide range of women, in the context of the US, obesity disproportionately affects minorities of lower socioeconomic status – due to a range of issues including forms of structural racism that limit access to health/health care and nutrient-rich food options (Ogden et al. 2013). Such a restriction must be seen, then, as further entrenching the enduring racialized cut in the administration of public health. Together, these factors highlight that fat gets to be valued and remediated only by women ‘already privileged’ within circuits of capital, demarcations of race, and normalizing judgments regarding embodiment. And, ultimately, it is the ideal neoliberal subject – that subject who is able to assume responsibility for their own health – who is the inheritor of this dream.

Second, fat technologies are inextricable from the vast circuitry of the breast cancer industry – what Smith (2012), writing for The Guardian, has called a multi-billion dollar juggernaut. This industry, which comprises an infinitely expanding list of corporations, organizations, and agencies, often diminishes the focus on – or masks – the causes of cancer and obfuscates the terror, pain, and death that can accompany a breast cancer diagnosis (Jain 2007). It often fails to protect health and instead potentially contributes to cancer rates (with some companies making both cancer-causing chemicals and drugs for cancer treatments), and it profits from the commodification of breast cancer through marketing and branding (which often appears as corporate benevolence). The marketing that takes place within the breast cancer industry writ large generally deploys dominant breast cancer discourse, a discourse that is generated through mainstream activism and which focuses on notions of survivorship, hope, restoration, and wholeness (Ehrenreich 2001). Moreover, this discourse often supports the idea that individuals should think of themselves as enterprising their own health (Klawiter 2008) and calls on individuals to triumph over cancer.¹⁹ Biotech companies and plastic surgeons, in turn, draw on this rhetoric in order to market breast reconstruction technologies using fat and could at least in part be said to participate in the breast cancer industry – in that they profit from the corporeal aftermath of breast cancer.²⁰ This operation is clearly evident in Cytori Therapeutics' marketing of their RESTORE procedure, which carries the slogan, ‘Your Fat Can Redefine Your Recovery’; such a slogan links optimum ‘recovery’ to the capacity to remediate fat and addresses breast cancer patients who already think of themselves as enterprising survivors. In doing so, the company participates in interpellating these subjects – calling them into existence – and, like much of the marketing surrounding fat technologies, converts the liberal subject into the entrepreneurial neoliberal market actor who can direct and purchase their own restoration or regeneration through fat.

Inarguably, new markets of and for the body are being imagined and inaugurated – conjuring into existence new corporeal materialities through fat. Yet, the Promethean tale that fat represents carries with it a series of contingencies: the fount of fat is not endless (the body contains only so much); the capacities of fat are not infinite (for instance, fat stem cells cannot infinitely transform) and the body must be disaggregated to enable these capacities (either through the literal redistribution of body parts or through disaggregation that occurs at a cellular level); and fat growth can lead to an excess of life that can cause death (turning this ‘dream’ into a nightmare). Taking a wider lens, the epistemological reordering of fat is ultimately and undeniably dependent on the domain in which it operates – or is operationalized – and the bodies it is associated with, and it is always already enmeshed within broader regimes of value and circuits of capital. As such, despite all possible new imaginings of the body, value, and life itself, the medico-technological deployment of fat must be seen as that which raises questions about boundaries and limits ‘in the very promise’ of excess, boundlessness, and regenerability (who has access, under what conditions, what are the costs and contingencies of such technologies). Ultimately, while bioprospecting for breast-making gold might offer the opportunity to reformulate living processes and increase the vital yield of the body, and while it might suggest a new form of endless value production, is it nevertheless conditioned and constrained by material relations and underscored by the still-present limits of matter itself.

Notes

1. See Ehlers (2012 and forthcoming).

2. Exploring this delineation is beyond the scope of this paper. It is, however, a necessary area for further investigation.

3. I have considered these concerns elsewhere (Ehlers 2012). Also see Hallowell (2000), Crompvoets (2006), Broom (2001), and Manderson (1999).

4. The first fat graft was performed in 1893 by German physician, Franz Neuber, who grafted a piece of upper arm fat to a patient's cheek in order to correct a visible ‘defect’.

5. On the DIEP procedure, see Gill et al. (2004), on the SIEA, see Nahabedian et al. (2002), and on TUG and the GAP, see Blondeel (1999).

6. Part of what makes this procedure so successful, according to Khouri, is that stem cells are naturally transferred in the lipoaspirate. Note, however, that this technology is not considered a ‘stem cell technology’. See The Miami Breast Center website page ‘Fat Transfer, Grafting to Breast Using Stem Cells Truth and Myth’. Available at: http://www.miamibreastcenter.com/stem-cells-fat-transfer.

7. See, for instance, ‘Increased Breast Cancer Risk Associated with Greater Fat Intake’, Journal of the National Cancer Institute (March 21, 2007) quoted in ScienceDaily. Available at: http://www.sciencedaily.com-/releases/2007/03/070321161542.htm (accessed 11 March 2014). Also see ‘Obesity and Cancer Risk,’ available at US National Institute of Cancer at the National Institute of Health: http://www.cancer.gov/cancertopics/factsheet/Risk/obesity. A UK study estimated that around 9% of breast cancers in women in the UK in 2010 were linked to excess bodyweight (Parkin and Boyd 2011).

8. As Locke, Feisst, and Dunbar (2011) highlight, however, the clinical potential of human ASCs is still unclear and requires deeper investigation.

9. In saying this, my claim is that breasts are not necessary in order for the subject to stay alive. Undeniably, however, breasts play a large role in reproductive labor (that is, in terms of breastfeeding) and, thus, in the survival of children.

10. See ‘New Breast Reconstruction Procedure Demonstrates Long Term Success in European Trial; Data Reported From Cytori's RESTORE-2 Study of the Celution(R) System’. Available at: http://ir.cytori.com/files/doc_news/CYTX_News_2011_3_2_General.pdf. Two clinical trials have been conducted using RESTORE, and it has been approved for use (and is being used) in Australia (see: <http://ir.cytori.com/investor-relations/News/news-details/2013/Cytoris-Celution-System-Approved-in-Australia-for-Processing-and-Delivering-Adipose-Derived-Regenerative-Cells/default.aspx>).

11. See the Neopec homepage: <http://www.neopec.com.au/>.

12. The clinical trial for the Neopec technology was completed in late 2012 and proof of principle was established. See ‘Neopec Clinical Trial Completed’. Available at: <http://www.neopec.com.au/index.php/recent-news/89-2012/132-neopec-clinical-trial-completed>.

13. My thinking on the distinctions between transfer technologies and regenerative medicine are indebted to Melinda Cooper. In her path-breaking book, Life as Surplus (2008), she argues that, with regenerative medicine, ‘[t]he point-to-point movements of pregiven bodies give way to the morphogenesis of form as process’ (2008, p. 105). While Cooper's understanding of tissue transfer can be applied to fat transfer, her argument regarding tissue autogenesis must be amended when accounting for the use of fat stem cells. For Cooper, stem cell research is concerned with perpetual self-transformation (2008, p. 127). This argument does not hold for stem cell research using fat in breast reconstruction, where there is a teleological endpoint to self-transformation through the animation of the stem cell: perpetual transformation is not the goal but, rather, the materialization of a breast. Also see Squier (2004) on the differences between what she calls replacement and regenerative medicine.

14. See the BioLife Cell Bank ‘Banking Packages’ website. Available at: <http://www.biolifecellbank.com/for-patients/service-packages/>.

15. See ‘Stem Cell “Cowboy Culture” Emerging in Texas – and Australia’ in the Stem Cell Foundation of Australia e-newsletter, April 2013. Available at: <http://www.stemcellfoundation.net.au/news/newsletters/april-2013>. Also see Sophie Scoot and Alison Branley, ‘Stem Cell Warning: Experts Fear Experimental Treatments Will Lead to Serious Injury’. ABC News, December 13, 2013. Available at: <http://www.abc.net.au/news/2013-12-18/stem-cell-warning3a-experts-fear-experimental-treatments-will-/5164636>.

16. This has the potential to rework existing discourses of obesity, though the reality of such practices is still a long way off.

17. See ‘Cancer Fact and Figures for African Americans’, American Cancer Council. Available at: <http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-027765.pdf>.

18. Just over a decade ago, Spear, Mardini, and Ganz (2003) put the average cost of TRAM flap reconstructions at $19,607 (range $11,948–$49,402), compared with $15,497 for prosthetic reconstructions (range $6422–$40,015). According to US News, the cost of breast reconstruction has more than trebled in the last decade (see Doheny 2011).

19. Also see Ehlers and Krupar (forthcoming).

20. Another example of such an operation is evident in ‘Breast Reconstruction Month’, which is a relatively new US and Canadian event ostensibly dedicated to raising patient awareness as to what kinds of breast reconstruction are available for women. Importantly, however, in the US the event is sponsored by the American Society of Plastic Surgeons and by major Biotech companies, such as Life Cell (who have developed a fat processing technology called REVOLVE™ System), highlighting another way that financial capital is inextricable from cancer activism.