E. Delay

Fat Injection to the Breast: Technique, Results, and Indications Based on 880 Procedures Over 10 Years

BACKGROUND Fat injection to the breast is not a new idea, but it has always been controversial. In particular, it has been feared that breast augmentation with autologous fat could lead to the formation of calcifications and cysts that might hinder mammagraphic examinations for detection of possible breast cancer. OBJECTIVE The authors report their experience with fat transplantation in the breast (lipomodeling) covering 880 procedures performed over the past 10 years. They review their technique and results, and describe the various indications for which they have found lipomodeling to be appropriate. METHODS Lipomodeling was generally performed under general anesthesia. Fat was harvested from the abdomen or in some cases from the inner thighs, depending on the patients natural fat deposits. The harvested fat was centrifuged to obtain purified fat, which was transferred to 10-mL syringes for injection directly into the breast. Fat was injected in small quantities under light pressure, utilizing a honeycomb of microtunnels and halting when the recipient tissues were saturated to avoid creation of fatty pools that could lead to fat necrosis. To compensate for fat resorption, 140 mL of fat was injected for a desired final volume of 100 mL. RESULTS Clinical follow-up shows that the morphologic results of lipomodeling with regard to the volume obtained are stable three to four months postoperatively if the patients weight remains constant. The postoperative radiologic appearance is usually that of normal breasts, sometimes showing images of fat necrosis that will not confuse the differential diagnosis of cancer for radiologists experienced in breast imaging. Oncologic follow-up at 10 years postoperatively (for the first patients) showed no increased risk of local recurrence of cancer or development of a new cancer. Results were highly satisfactory for both patients and surgeons. Complications included one case of infection at the harvest site, six cases of infection at the injection site, and one case of intraoperative pneumothorax that was successfully treated in the recovery room with no later consequences. The incidence of fat necrosis was 3%, with most cases occurring early in the surgeons experience. CONCLUSIONS Lipomodeling, because of a low complication rate and positive results, presents a new option for plastic, reconstructive, and aesthetic surgery of the breast. Pre- and postoperative examination by a radiologist specialized in breast imaging is necessary to limit the risk that a cancer may occur coincidentally with lipomodeling.

Breast fat grafting (lipomodelling) after extended latissimus dorsi flap breast reconstruction: a preliminary report of 200 consecutive cases.

BACKGROUND The efficacy of fat grafting has long been a controversial issue. Breast lipomodelling after extended latissimus dorsi flap reconstruction was first attempted at the Plastic and Reconstructive Surgery unit of Leon Berard Cancer Centre in 1999. We present the results of a retrospective report of the first 200 consecutive patients treated at our institution from 1999 to 2003. METHODS We identified specific requirements of the patients, and collected information on the surgical techniques used and the volumes of fat tissue injected. We analysed and compared the results of a total of 244 lipomodelling sessions. RESULTS The graft consisted of 70% fat graft, 13% oily supernatant and 17% serum residues. Approximately 30% was lost during centrifugation. On average, 176 ml of fat were injected in each breast. Very satisfactory results were obtained in 94.5% of the cases, with a majority of patients (80%) being very satisfied with the procedure and only 1.5% complications. CONCLUSION Our results demonstrate the safety and feasibility of breast lipomodelling. It is a new approach to improve reconstructive outcome after extended latissimus flap breast reconstruction.

Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction.

Background: Creation of the nipple-areola complex is the final step in surgical restoration of the breast. Often considered as a secondary complement to breast reconstruction, nipple-areola reconstruction is usually done after an interval of several months and makes use of composite graft techniques involving the opposite nipple or local flaps. Methods: Because the position of the nipple-areola complex is defined from the outset in skin-sparing mastectomy and because of the disappointing results obtained by classic nipple reconstruction techniques, the authors propose immediate nipple reconstruction using the skin paddle of the latissimus dorsi flap. Once the flap has been raised and placed in the skin-sparing mastectomy site, its paddle is folded back onto itself to form a cone. Two dermal-fat flaps are lifted at the top of the cone and sutured together to form the new nipple. Results: Thirty patients (mean age, 49 years; range, 43 to 60 years) underwent immediate nipple reconstruction between May of 1999 and December of 2001. A retrospective study of the 30 cases was conducted with a mean follow-up of 16.5 months (range, 2 to 31 months). Mean residual projection was 7.8 mm after 1 year in 20 patients and 6.8 mm after 2 years in eight patients. Patient satisfaction with nipple projection was studied by means of a questionnaire. Seventy percent of patients considered the result very good, 23.3 percent considered it good, 6.6 percent considered it medium, and none considered it poor. Conclusions: On a psychological level, immediate nipple reconstruction seems to help assimilation of the reconstructed breast in the body image and leads to considerable patient satisfaction. Nipple reconstruction should no longer be considered as a secondary complement to immediate breast reconstruction. From the patient’s viewpoint, the nipple appears to be an essential component of breast reconstruction.

Tuberous breast correction by fat grafting.

INTRODUCTION Tuberous breast is a rare malformation that has negative physical and psychological impacts during puberty. A range of surgical techniques has been used to correct breast shape and volume in this context, including a combination of skin plasty and mammary gland remodeling, as well as prostheses and locoregional flaps. The authors have used fat grafting as a complementary technique to correct tuberous breasts since 1998. OBJECTIVES The authors discuss application of their lipomodeling technique for correction of tuberous breast deformity. METHODS The charts of tuberous breast patients treated consecutively over an 11-year period (n = 31) solely with fat grafting (ie, without using an implant) were retrospectively reviewed. Each breast deformation was graded according to the Grolleau classification. The number of sessions and the mean transfer of fat volume by lipomodeling session were recorded. Patient and surgeon satisfaction were evaluated. RESULTS Of the 31 patients in this series, 18 had bilateral formations and 13 had unilateral malformations. The mean patient age was 23 years, and the mean body mass index was 21.9. A single session (mean transfer volume, 158 mL; range, 90-253 mL) was required in 14 (45%) cases. A second session (mean transfer volume, 226 mL; range, 100-316 mL) was necessary in the remaining 55% of cases. Mean follow-up period after the last fat transfer session was 6.5 years (range, 1.5-11 years). Patients were very satisfied in 94% of cases (n = 29) and satisfied in 6% (n = 2). The surgical team rated 94% of cases as being successful or very successful. No complications were observed. One patient developed hypertrophy of the treated breast following weight gain and thus required breast reduction. Imaging performed preoperatively and 1 year postoperatively did not reveal any anomalies other than oil cysts. CONCLUSION Fat grafting is a reliable technique that produces excellent results and high levels of patient satisfaction for the treatment of tuberous breast. The aesthetic outcome is natural, implant free, and long lasting. LEVEL OF EVIDENCE 4.

Reconstruction mammaire par transfert graisseux exclusif : à propos de 15 cas consécutifs

UNLABELLED BACKGROUND OF STUDY: The purpose of this prospective study is to detail the preliminary results, the advantages and drawbacks of a new iterative fat transfer protocol in selected breast reconstructions. MATERIAL AND METHODS Fifteen patients had breast reconstruction following mastectomy for breast cancer by this iterative lipomodeling protocol, between 2002 and 2007. Clinical and technical aspects are described. Indications, advantages, drawbacks, complications and morphological results are discussed. RESULTS Mean age at first stage procedure was 50 years (min: 41, max: 57). Indications were eight delayed breast reconstructions, three salvage reconstructions after flap failure, two restorations following primary chest wall reconstruction, two immediate breast reconstructions. Two to five sequential procedures were necessary to obtain a satisfactory breast volume (mean: three procedures). Mean total transferred fat volume was 600 cm(3) (min: 266 cm(3), max: 926 cm(3)). Multiple procedures were performed: restoration of breast skin envelope by abdominal advancement fasciocutaneous flap, breast contours liposuction, controlateral breast symmetrisation, nipple areola complex reconstruction. Mean follow-up was 28 months. The aesthetics results have been judged as very good in 10 patients, good in four patients and poor in one patient. The satisfaction rate of the patients is high: 10 patients are pleased, four patients are satisfied and one patient is moderately satisfied. CONCLUSION Fat transfer alone can efficiently restore breast volume after mastectomy, granting all advantages related with autologous reconstruction. No donor site morbidity is present; in fact some secondary benefits are observed thanks to the correction of eventual disgraceful lipodystrophies. These secondary benefits strengthen patient compliance improving iterative procedures tolerance. Lack of available adipose tissue and high breast volume are the major morphological limits of the technique. In our experience, fat transfer appears to be a promising technique for breast reconstruction. Long term results still have to be evaluated before it can become a standard.

Percutaneous fasciotomies and fat grafting: indications for breast surgery.

BACKGROUND The management of breast deformities can be very difficult in the presence of breast shape retraction. Percutaneous fasciotomies, which release fibrous strings, can be a very useful tool for shape improvement in the recipient site for a fat graft. OBJECTIVES The authors evaluate the efficacy of fasciotomies in association with fat grafting in breast surgery. METHODS A retrospective chart review was conducted for 1000 patients treated with concurrent fasciotomies and fat grafting between January 2006 and December 2011. The recipient site was prepared with fasciotomies, and fat was harvested from other parts of the body using a low-pressure 10-mL syringe lipoaspiration system. Fat was centrifuged and injected into the breast for reconstruction or chest deformities. The postoperative appearance of the breast scars was scored by both the surgeon and the patient. Each complication was recorded, including instances of hematoma, infection, tissue wounds, scar healing, and fat necrosis. RESULTS In this series of patients, for whom the primary indications for the procedure were sequelae of breast-conserving surgery after cancer, latissimus dorsi flap breast reconstruction, breast implant reconstruction, tuberous breast, Poland syndrome, and funnel chest, we recorded the following complications: 0.8% local infections (8/1000), 0.1% delayed wound healing that required medical care (1/1000), and 3% fat necrosis (31/1000). Fasciotomy scarring was considered minor by the patient in 98.5% of cases and by the surgeon in 99% of cases at 1 year postoperatively. CONCLUSIONS Fat grafting is a safe and reliable technique that improves the aesthetic outcomes of breast surgery. Percutaneous fasciotomies provide excellent aesthetic results and an improvement in breast shape with no scarring. In our experience, both fat grafting and fasciotomies offer a durable result over the long term.

Patient Information Before Aesthetic Lipomodeling (Lipoaugmentation): A French Plastic Surgeon's Perspective

Fat grafting to the breasts has long been controversial among aesthetic surgeons. We have developed a new, safe, effective, and reliable lipomodeling method to be used in breast augmentation. This method grew out of our clinical and radiologic experience acquired since 1998 with fat injections to the breast. The aim of the present report is to provide facts and data concerning lipomodeling and to document our procedures for ensuring that clear, consistent, up-to-date information is given to the patients who are undergoing aesthetic lipomodeling. The key element in our preparation is our commitment to avoid missing the diagnosis or altering the presentation of a preexisting or newly arising breast cancer. We must also ensure that the patient understands the need to comply with follow-up recommendations, such as a specific radiologic examination before and one year after the procedure, as well as a biopsy evaluation of any lesion that is considered suspicious during the physical examination. The patient must sign a confirmation that she has received the appropriate information and that she understands the notice provided by the surgeon at her first visit. This notice must deliver clear, complete, objective, evidence-based information, must be written clearly and understandably, and must not contain any unrelated or confusing information.

Breast Amputation Correction of a Horse Bite Using the Lipomodeling Technique

UNLABELLED Mammary gland development is an important phase of puberty, and it marks the passage into adulthood for women, so any trauma leading to mammary deformities has an important physical and psychological impact. Often, classic techniques are difficult to use in the treatment of traumatic breast lesions. In this article, the authors present an exceptional case of breast reshaping by lipomodeling in a teenage patient who had experienced a horse bite. Treatment included 2 fat grafting sessions with fasciotomies, nipple reconstruction using a bifoliated flap, and areolar tattooing, all without any complications. We achieved a satisfactory result with a symmetric volume, a natural tissue consistency, and sensation improvement, all of which were maintained as the patient grew. In our experience, fat transfer was a safe and reliable technique that provided a good and stable aesthetic result, improving the volume and shape without additional scarring or implant devices. LEVEL OF EVIDENCE 5.

Reconstruction mammaire bilatérale par lambeau myocutanéograisseux de grand dorsal (31 cas consécutifs)

PURPOSE OF THE STUDY The purpose of this study was to analyse the advantages, disadvantages and results of bilateral breast reconstruction by autologous latissimus dorsi flap. MATERIAL AND METHOD Thirty-one two-stage consecutive bilateral breast reconstructions were performed by the same operator between 1993 and 2001. All the reconstructions, in immediate or delayed manner, were indicated after radical or skin sparing mastectomy for breast cancer. We used the autologous latissimus dorsi flap for all cases. The reconstruction of the second breast was always delayed of a few months to avoid backs complications. We reviewed the charts of these patients retrospectively. Preoperative data, postoperative complications, dorsal seroma occurrence, morphological results and patients satisfaction were evaluated. Median follow-up was 22 months. RESULTS The results confirm the procedures reliability. Comparative rates of postoperative complications are not significantly different between first and contralateral breast reconstruction. Functional after-effects of bilateral latissimus dorsi harvesting are moderate. The aesthetics results have been judged as very good in 84% of cases and good in 16%. The satisfaction rate of the patients is high: 90,3% are pleased, 6,5% are satisfied and 3,2% are moderately satisfied. CONCLUSION The autologous latissimus dorsi flap allows a two-stage bilateral breast reconstruction. This procedure is not indicated for simultaneous bilateral breast reconstruction; it is the main drawback of this technique. So we believe that this procedure is an excellent alternative in all the indications of sequential bilateral breast reconstructions.

Un risque inhabituel de la liposuccion : la liposuccion d’une tumeur maligne. À propos de 2 cas

Resume La lipo-aspiration est un moyen elegant et simple de traiter certains excedents de tissu graisseux ; son utilisation s’est rapidement etendue au traitement des lipomes et de certaines gynecomasties. Le but de cet article est de presenter 2 observations d’un risque exceptionnel de la liposuccion : la liposuccion de tumeurs malignes. Les cas cliniques de 2 patients, adresses dans le service pour la prise en charge de cette complication, sont etudies pour illustrer ce propos : la liposuccion d’une « gynecomastie » chez un patient porteur d’un cancer du sein, et la lipo-aspiration d’un « lipome » de la cheville chez une patiente presentant en fait un liposarcome. Pour eviter de lipo-aspirer et disseminer une tumeur maligne, l’examen preoperatoire doit s’orienter vers la recherche de particularites cliniques evoquant le diagnostic : une gynecomastie unilaterale, irreguliere, indolore ou dure chez un homme d’âge mur doit faire preferer une exerese chirurgicale classique, de meme qu’un lipome recidivant, dependant des plans profonds, volumineux ou rapidement extensif, situe sur les membres ou dans la region scapulohumerale. Des examens paracliniques peuvent etre discutes. Il faut recuser d’emblee les cas douteux, qui doivent imperativement beneficier d’une exerese chirurgicale avec marges de securite strictes et examen anatomopathologique complet de la piece. La liposuccion est devenue un outil d’appoint tres utilise en chirurgie plastique ; ses nombreux avantages ne doivent pas faire oublier le risque de liposucer une tumeur maligne, c’est-a-dire de disseminer un cancer meconnu au moment de l’intervention. Tout chirurgien doit garder a l’esprit ce risque et preferer au moindre doute une exerese chirurgicale.