The treatment of sequelae after conservative breast cancer treatment can be a challenge. Lipomodeling, although controversial in the beginning, is a safe technique that can help in the treatment of these deformities, without an important impact on the imaging surveillance. Depending on the severity of the deformity, one or several sessions of fat transfer can be required. The technique is easy and reproducible, but before obtaining satisfying results with a low complication rate, a learning curve should be completed. The final result is natural, with normal breast consistency, with no additional scars.
Key points
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Sequelae after conservative breast cancer treatment are deformities difficult to treat with the classic approach.
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Lipomodeling is a reproducible technique with very good results, but the surgical plan should include one or more fat transfer sessions.
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The radiologic impact of fat grafting to the breast is not different from that observed with other breast surgeries.
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The advent of fat grafting to the breast revolutionized the aesthetic results with a natural volume replacement.
Introduction
The sequelae after conservative breast cancer treatment are a challenge, and until now, no technique gave a very good result. Flaps, like the latissimus dorsi musculocutaneous flap, were the only treatment proposition, and usually they were associated with new scars and long surgery and recovery.
Most often, patients who had conservative breast surgery present for correction of the remaining deformity a few years after the end of cancer treatment, when they are ready to move forward and get over this episode of their life. Correction of the deformity allows them to reintegrate the breast into their body image.
After very good results achieved with fat transfer in breast reconstruction, the authors have decided to try and use it for the treatment of conservative breast surgery sequelae. This decision was supported by an imaging study that they conducted on breast reconstruction–associated fat grafting. This study showed no new pathologic lesion and no impact on the screening process.
The purpose of this article is to present the information that should be presented to patients and the preoperative workup, surgical technique, results that can be obtained, advantages and disadvantages, eventual radiologic modifications after lipomodeling, and in the end, the medicolegal aspects linked to a coincidence between the appearance of a local recurrence and fat transfer.
Introduction
The sequelae after conservative breast cancer treatment are a challenge, and until now, no technique gave a very good result. Flaps, like the latissimus dorsi musculocutaneous flap, were the only treatment proposition, and usually they were associated with new scars and long surgery and recovery.
Most often, patients who had conservative breast surgery present for correction of the remaining deformity a few years after the end of cancer treatment, when they are ready to move forward and get over this episode of their life. Correction of the deformity allows them to reintegrate the breast into their body image.
After very good results achieved with fat transfer in breast reconstruction, the authors have decided to try and use it for the treatment of conservative breast surgery sequelae. This decision was supported by an imaging study that they conducted on breast reconstruction–associated fat grafting. This study showed no new pathologic lesion and no impact on the screening process.
The purpose of this article is to present the information that should be presented to patients and the preoperative workup, surgical technique, results that can be obtained, advantages and disadvantages, eventual radiologic modifications after lipomodeling, and in the end, the medicolegal aspects linked to a coincidence between the appearance of a local recurrence and fat transfer.
Technique justification
The use of fat grafting in breast surgery is an old concept. In a more recent period, Illouz and Fournier suggested from the beginning of modern liposuction to use the aspirated fat to obtain moderate breast augmentation. Bircoll presented the same technique and underlined the advantages of this technique : easy, no scars, early return to normal activities, and no implant, without talking about the secondary benefit of liposuction of the donor areas. These 2 articles resulted immediately in many very outspoken opposing reactions. The critics insisted on the fact that fat injections in a normal breast can produce microcalcifications and cysts, making it difficult to detect cancer. Even if Bircoll explained in his replies that the calcifications after fat transfer are different in localization and radiologic aspect than those seen in tumors, and that after breast reduction the same aspects are encountered and they do not effect breast screening, the result of the debates remained negative for fat grafting to the breast.
In 1998, the purpose of the authors’ research subject on fat transfer to the breast was to improve the technique to decrease the fat necrosis images and to tackle the taboo that suspended any work in breast fat grafting.
Observing the efficacy and success that fat grafting had when transferred to the face, the authors came up with the idea to use this technique in breast reconstruction. At first, they used fat grafts in addition to breast reconstruction with total autologous latissimus dorsi flap. Afterward, they widened the indication for most patients who had breast reconstruction by autologous latissimus dorsi flap and desired a better result, with a better cleavage, better breast form, and consistency. The authors conducted an imaging study using mammogram, ultrasound, and MRI. This study showed that the impact on breast imaging did not interfere with cancer surveillance. For this reason, they progressively widened fat grafting indications for different breast reconstruction cases, then for thoracic mammary malformations, to the breast conservation treatment sequelae, and more recently, in aesthetic surgery of the breast. The first presentations to the French Society of Plastic and Reconstructive Surgery and worldwide received the same hostile polemic as the earlier work in 1987. The authors responded point for point, and with every presentation, the hostile reactions diminished, and, in the end, fat grafting was adopted as one of the techniques used in breast reconstruction.
Patient information
The first consultation should expose the patient’s medical history and her expectations from the reconstruction. Each patient is informed in detail by informed consent about the operation, advantages, disadvantages, and possible complications. The authors focus particularly on fat loss that is normal in the first months, on the fact that a second surgery may be needed if the initial deformity is severe, and on variation in result with weight changes. They also inform the patient about ecchymosis and the minimal scarring that are to be expected in the donor site.
A thorough clinical examination is performed with the patient standing, and the affected breast is compared with the contralateral breast in order to identify and mark the areas that need correction. The authors also evaluate breast symmetry, global volume, fullness, nipple-areola complex position, importance of global volume loss, and presence of retractile scars. They evaluate the volume of fat needed to harvest and transfer, and the associated procedures, like fasciotomies, symmetrization or nipple reconstruction, and areola tattoo. They identify fat donor sites. Most often they harvest from the abdominal area, because it does not require positional change during surgery; the second choice for harvesting is the trochanteric region, often in combination with harvest from the inner thighs and knees and also from the posterior thighs. The patient should have stable weight when surgery is performed because the transferred fat retains the memory of the donor site, and if the patient loses weight after lipomodeling, she is going to lose a part of the surgery benefit.
Before lipomodeling, the pathology result of the initial breast cancer, to confirm that the resection was complete, and consent from her oncologist are needed.
According to the authors’ protocol, all patients have ultrasound, mammogram, and breast MRI before surgery and breast ultrasound and mammogram 1 year after surgery.
The risk of recurrence is clearly explained to the patient along with the risk of a coincidental occurrence between lipomodeling and local relapse. In the case of recurrence, a mastectomy and immediate breast reconstruction can be performed.
Surgical technique
The lipomodeling technique used in the treatment of breast conservation deformity is derived from that used for breast reconstruction. The purpose of fat grafting is to transfer fat from a site where it is in excess to the breast with a deformity or volume deficit after breast conservation treatment. The operation is performed under general anesthetic. One dose of prophylactic antibiotic is administered intraoperatively.
The installation and the sterile field are planned so the patient position can be changed from dorsal decubitus to a sitting position in the case of abdominal and suprailiac harvesting, and from the prone position to the dorsal decubitus and sitting position if the fat harvesting is from the trochanter, internal thigh, and the under the gluteal regions.
The fat grafts are harvested using a blunt 3.5-mm cannula ( Fig. 1 A ) linked to 10-mL Luerlock syringes after infiltration with saline and epinephrine solution (1 mg epinephrine in 500 mL saline). The incisions are performed with a no. 15 scalpel, and their position depends on the area to be harvested. The abdominal fat is harvested through 4 periumbilical incisions; the flanks through suprailiac incisions, one on each side; for the trochanteric and gluteal regions, the incisions are made into the gluteal fold. The surgeon creates small and progressive negative pressure (2–3 mL) in the syringe using the hand in order to reduce the trauma exerted on the adipose tissue (see Fig. 1 A). The authors harvest the deep and superficial fat. At the end of the operation, the harvest site is improved by liposuction and a Naropein 7.5 mg (Ropivacaine) 50% solution is infiltrated to decrease the postoperative pain in the first 24 hours after surgery. The incisions are closed with rapid absorbable sutures.
While harvesting, the nurse treats the filled syringes by centrifugation: a cap is used to cover the end of the syringe, and the piston is retrieved. Then, the syringes are introduced 6 at a time into the centrifuge, and they are centrifuged 20 seconds at 3000 rotations per minute. At the end of centrifugation, the fat has 3 phases (see Fig. 1 B,C):
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The lower part containing blood and saline;
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The middle part containing the purified adipocytes; this part is the one that is going to be transferred;
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The upper part containing the oil resulted from the cellular lysis (chylomicrons and triglycerides).
After preparation, the fat grafts are transferred using several small incisions performed with an 18-G needle. The fat grafts are transferred in a 3D crisscross pattern using a 2-mm cannula (see Fig. 1 D). The fat is transferred from the deep planes to the superficial ones following the preoperative markings. The fat transfer is performed in small quantities while withdrawing the cannula without putting too much pressure on the syringes piston, following the principle of fat “spaghetti” (see Fig. 1 E), because injecting too much fat into one area can produce fat necrosis cysts (the centripetal revascularization is not enough for the large fragments, which become the site of central necrosis and cyst formation).
Volume overcorrection is required if possible, because the fat resorption is about 30%. In cases of breast conservation deformities, hypercorrection is not possible because the recipient tissues do not allow it due to the fibrosis; that is why a second and even a third fat grafting session is often required. Usually, the second operation will allow the transfer of more important quantities of fat grafts due to the antifibrotic effect of the fat injected during the first surgery.
In the authors’ opinion, it is best to start with moderate deformity correction, and after mastering the learning curve, more severe deformities can be treated using fat grafting and fasciotomies in multiple sessions. At the end of surgery, a simple dressing is applied to the treated breast, avoiding any compression, and a compressive dressing is applied to the harvest sites.
Postoperative care
The patient leaves the hospital the same day or the day after surgery. Mild analgesics are prescribed. The simple dressing is changed every 72 hours. The compressive dressing in the harvest site is kept in place for 5 days. Often the harvest sites are marked by ecchymosis, and usually they are the most painful after surgery. The breast also has edema and ecchymosis, but milder than in the harvesting sites. The donor site ecchymosis disappears in about 3 weeks, and sometimes they may present some nodular indurated areas, which normalize over a few months after surgery.
The end result can be observed 3 months after surgery, but after the first month, the breast is supple and natural to touch. In case of insufficient correction, 1 or 2 supplementary sessions can be performed, each 3 or 4 months apart.
Results
The authors’ first results were published as a series from 2002 to 2007. The average age of the patient was 50.7 years, ranging from 35 to 64 years. The average body mass index was 21.8 kg/m 2 . Fifty-four operations were performed for 42 patients with an average 1.3 surgeries per patient; 22% of patients needed a second surgery, and only one patient needed a third surgery (2.4%).
The results were evaluated by 2 surgeons using a clinical examination and photographs of each patient before and after surgery; 93% of these results were evaluated as good and very good ( Fig. 2 ). The results can be evaluated using photo-documentation ( Fig. 3 ). The patients were satisfied or very satisfied in 90% of cases. If the patient is not satisfied, the authors propose a new session of lipomodeling in order to obtain the desired result.
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