Breast lipomodeling, or breast fat grafting, is a major development in breast plastic surgery. This technique has a low complication rate, excellent results, and patient acceptance. Radiologic evaluation mostly shows a normal-appearing breast. During breast reconstruction, fat grafting is the ideal complement of the latissimus dorsi flap. Fat grafting for Poland syndrome seems to be a great step and will most likely drastically change the surgical treatment of severe cases. Finally, lipomodeling is a new alternative in the treatment of pectus excavatum, tuberous breasts, and breast asymmetries.
Key points
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Careful preoperative clinical and radiologic assessment and clearance for the procedure are mandatory before fat grafting.
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Fat must be transferred in multilayers, starting from the deep plane to the superficial one.
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Fat must be transferred in fine tunnels (like the shape of a spaghetti noodle) in a regular manner to avoid fat necrosis.
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Fat transfer should be interrupted when the recipient site is saturated.
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Resorption rates and fat and recipient site quality must be taken into account to initially overcorrect the volumes.
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Great caution is mandatory when transferring fat in the subclavian region, especially in patients with Poland syndrome, because subclavian vessels may be situated much lower than in normal anatomy.
Overview
Breast fat transfer is an old concept. In 1895, Czerny described the use of a voluminous lipoma to fill the breast after excision of a fibroadenoma. Several researchers have then used different techniques for breast augmentation and reconstruction. The techniques developed at the beginning of the 1980s were controversial. This controversy became so significant after the work of Bircoll, and the American Society of Plastic and Reconstructive Surgery released a committee recommendation as follows:
The committee is unanimous in deploring the use of autologous fat injection in breast augmentation, much of the injected fat will not survive, and the known physiological response to necrosis of this tissue is scaring and calcification. As a result, detection of early breast carcinoma through xerography and mammography will become difficult and the presence of disease may go undiscovered.
This decision was the end of the research and evaluations in this field. Comprehensive debate about this topic can be found in the authors’ article published in 2009. Following the work of Coleman depicting the efficacy of fat transfer in the face, we evaluated fat grafting in breast reconstructive and plastic surgery. As the main criticism of fat transfer in breast reconstructive surgery was the potential radiologic consequences, we studied them on a scientific basis. We then applied fat grafting to the different techniques of breast reconstruction, sequelae of conservative breast surgery, and breast malformations.
Overview
Breast fat transfer is an old concept. In 1895, Czerny described the use of a voluminous lipoma to fill the breast after excision of a fibroadenoma. Several researchers have then used different techniques for breast augmentation and reconstruction. The techniques developed at the beginning of the 1980s were controversial. This controversy became so significant after the work of Bircoll, and the American Society of Plastic and Reconstructive Surgery released a committee recommendation as follows:
The committee is unanimous in deploring the use of autologous fat injection in breast augmentation, much of the injected fat will not survive, and the known physiological response to necrosis of this tissue is scaring and calcification. As a result, detection of early breast carcinoma through xerography and mammography will become difficult and the presence of disease may go undiscovered.
This decision was the end of the research and evaluations in this field. Comprehensive debate about this topic can be found in the authors’ article published in 2009. Following the work of Coleman depicting the efficacy of fat transfer in the face, we evaluated fat grafting in breast reconstructive and plastic surgery. As the main criticism of fat transfer in breast reconstructive surgery was the potential radiologic consequences, we studied them on a scientific basis. We then applied fat grafting to the different techniques of breast reconstruction, sequelae of conservative breast surgery, and breast malformations.
Treatment goals
Breast and thoracic lipofilling has numerous indications in breast surgery. Breast volume, shape, projection, consistency, and contour can be enhanced with this technique.
Latissimus Dorsi Reconstructed Breasts
Autologous breast reconstruction does not have the implant-related complications and produces a more natural breast. Latissimus dorsi flap transfer without an implant is to us the gold standard technique, as it has few postoperative complications and a better molding potential of thoracic volume. In some situations, however, reconstructed volume can be too small. The solution was then to add an implant under the flap. This solution was efficient, but reconstruction was no more autologous. In other situations, global results could be acceptable but some projection was missing or a localized defect prevented the results from being excellent. Lipofilling of a reconstructed breast has many advantages: autologous reconstruction process, cost-effectiveness, reproducibility, natural consistency and appearance of the breast, breast symmetry, and last but not least, treatment of fat deposits in the donor regions. Combined with lipomodeling, the autologous latissimus dorsi flap is our first choice in autologous breast reconstruction ( Figs. 1 and 2 ).
Latissimus dorsi flap is the most suited fat recipient because of its highly vascularized aspect. Our experience showed that a large quantity of fat could be transferred in 1 session (up to 500 mL per breast) with excellent results. Lipofilling is started from the bone plane to the pectoralis major and then to reconstructed breast, ending in the subcutaneous plane. Patients perfectly understand efficacy and concept of the technique and are then very satisfied with the surgery.
Implant Reconstructed Breasts
Implant reconstructed breast deformities are of 3 types : décolleté asymmetry with step appearance of prosthetic breast, medial deformity with step and too wide intermammary vallée, and lateral deformity with lack of volume above the anterior axillary line. Lipofilling represents 80 to 300 mL. In the décolleté, lipofilling is done in the pectoralis major muscle. In the internal part, lipofilling is in the pectoralis major and between the skin and capsule if implant change is planned. In the lateral aspect, lipofilling can be done only during an implant change, as it is between the skin and capsule ( Fig. 3 ).
It seemed to us that fat grafting reduced capsulitis formation, but further studies are needed to prove this effect.
TRAM or DIEP Reconstructed Breasts
Some researchers consider DIEP and TRAM flaps to be excellent breast reconstruction techniques. Some shape and volume defects can, however, be obvious. During the second stage of surgery, intrapectoral and intraflap fat grafting is done, mainly on locations which lack fullness. In some cases, lipofilling is done to increase global flap volume. It is mandatory to transfer less fat in a TRAM or a DIEP than one could do in a latissimus dorsi flap because the former are less vascularized. Another advantage of fat grafting secondary to TRAM or DIEP flap is the possibility to correct abdominal and flanks contour. This also prevent the need of secondary flap mobilization.
Breast Reconstruction with Fat Grafting Only
This technique is best suited for small or medium-sized breasts and patients presenting sufficient fat deposits. In a nonirradiated breast after mastectomy, 3 to 4 sessions are needed to achieve breast reconstruction with contralateral symmetry. In the presence of radiotherapy, 4 to 6 sessions are needed to obtain optimal results. This protocol has been evaluated and seems interesting for some specific conditions or to correct secondary cases after failed reconstruction.
Other Applications in Breast Reconstruction
Fat grafting can be done on very thin or irradiated skin 2 to 3 months before planned autologous or prosthetic reconstruction to prepare the thoracic area. In this indication, 80 to 200 mL of fat is transferred. Skin quality is enhanced and necrosis prevented. When thoracic malformation is present (eg, lateralized pectus excavatum), lipomodeling can correct deformity and enhance reconstruction and is then a “sur-mesure” (customized) reconstruction. Finally, fat grafting may be done on a native breast to enhance symmetry with a reconstructed breast, mostly in the décolleté region or to slightly increase the volume of the native breast. In this last indication, a preoperative and careful diagnostic imaging is to be done (ultrasonography and mammography) with a control at 1 year.
Corrections of Breast Conservative Surgery
In patients who underwent breast conservative surgery, the technique is done with strict radiologic screening. Risk of coincidence with a new cancer, or a recurrence of the previous one, is high. Our protocol includes an accurate radiologic breast status with mammographic, ultrasonographic, and MRI evaluation by an experienced breast imaging specialist. One year postoperatively, we achieve a new radiologic breast status with mammography and ultrasonography. If a suspect lesion is visualized, a microbiopsy is done. One study presented 42 patients with sequellae of breast conservative surgery in whom fat grafting was done in a strict radiologic protocol. The conclusions were that lipomodeling is a huge step in the therapeutic possibilities of surgical management of conservative surgery moderate sequelae. Breast imaging is not affected by the technique, and fat grafting does not prevent an accurate radiologic breast screening. This indication is the most troublesome, and we highly recommend that these patients be treated in a multidisciplinary setting.
Thoracic Malformations
Three indications, in a nononcologic setting, are presented here. Tuberous breasts can be an indication of lipomodeling. This technique can be done alone in about half of cases or in addition to implants or mammaplasty procedures. Fat grafting has, to us, highly modified the surgical treatment of tuberous breasts ( Fig. 4 ).
