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LIPOSTRUCTURE OF RECONSTRUCTED BREAST
AFTER MASTECTOMY

(Autologous fat grating or transfer to improve the quality of reconstructed breast)

Reconstructive surgery:
This document has been conceived under the authority of the French Society of Plastic Reconstructive and Aesthetic Surgery (SOFCPRE).

DEFINITION, AIMS AND PRINCIPLES

There are many methods of breast reconstruction after mastectomy. They can be classified in three categories:

Reconstruction by implant (or breast prosthesis: in general placed under the pectoral muscle)

Reconstruction by flap and implant (muscle and skin are transferred to the breast, and the missing volume is supplemented by an implant placed behind the muscle)

Autologous tissue reconstruction, using tissue from the patient (there is no material other than its own body). These autologous tissues can be flaps, the main ones are

those of the tummy:

The TRAM: using a rectus abdomini muscle with the skin of the abdomen below the navel, transferred, turned 180º, or reconnected in the armpit as a free microsurgical flap;

The DIEP flap: skin of the abdomen without the muscle, but still reconnected by microsurgery.

from the back: using the latissimus dorsi and its surrounding fat, with or without skin.

There are other more rare flaps like the gluteus maximus, or from the contralateral breast.

The techniques are so varied and can be adapted to different situations (thin, damaged skin, or important or not volume of the breast to reconstruct...) and the different needs of patients. The surgeon can choose the best solution to offer on a case-by-case basis.

Despite these sophisticated techniques, small defects often persist, like irregularities, lack of volume or projection, or asymmetric neckline. To correct these defects, even in exceptional cases rebuild the entire breast, it is possible to transfer fat from the patient using the technique of lipostructure.

This technique, derived from the technique of fat transfer in the face, also called lipofilling or lipomodelling, is widely used and mastered in reconstructive surgery of the breasts where it has made a breakthrough.

The principle of the technique of lipostructure is to transfer fat from a potential donor site of the patient (variable for each patient: abdomen, hips, thighs...) towards the breast-chest region where there is lack of volume (localized defects, especially in the neckline, or more global defects). This technique is actually a fat graft: this means that the fat should be revascularized by the recipient environment. The reinjections are in the pectoral muscle and under the skin for prosthetic reconstructions, or in all plans for reconstruction with autologous tissue.

Modern techniques of fat transfer can achieve a harmonious distribution of fat cells, making more limited the risk of fat cyst formation or poor take (fat necrosis).

The fat necrosis may manifest clinically as firm smooth mobile and painless nodules in the breast. Their clinical appearance is usually characteristic. Radiologically, these transfers of fat can result, as with any breast surgery, aesthetic or not (removal of benign or malignant tumours, breast reduction surgery, breast augmentation...) with calcifications (associated with wound healing).

These calcifications (macro and micro-calcifications) are different from those observed in breast cancers, and do not pose diagnostic problems for the experienced radiologists, who can get the help of ultrasound and MRI. However, if the transfer of fat may not cause breast cancer, it does not prevent recurrence, if it was to reappear in the form of local recurrence. In case of increase in the volume of swelling on the reconstructed breast, the rule should remain the same as in a native breast: when in doubt about radiographic findings, biopsies should be performed.

Currently, we can consider that a breast lipostructure made under the rules of art by a plastic surgeon experienced in this field, does not suppose a diagnostic challenge for a radiologist experienced in breast imaging.

The transfer of fat in the reconstructed breast is often done during a second operation, combined with other gestures of refinements of both breasts. It should be performed by a competent and qualified Plastic Surgeon, trained specifically for this type of technique and performing in a real surgical environment.

This intervention is part of the reconstruction, and is supported by health insurance.

BEFORE THE OPERATION

In general, the reconstruction project is developed jointly between the patient and the surgeon and the choice of reconstruction depends on many factors and the preference of the patient. Autologous reconstructions rely heavily on the pre-estimated available fat, and should be stable over time (no weight change: patients should find their weight balance before surgery).

Following the selection of the type of reconstruction, the stages of it will be detailed, and often including at the second operation lipostructure in other parts of the second phase of reconstruction (reconstruction of the areola and nipple, symmetrisation, liposuction of the inframammary crease).

Following this consultation:

A photographic record was started and continued throughout reconstruction.

A preoperative assessment is normally conducted as required.

The anaesthetist will be seen in consultation at the latest 48 hours before surgery.

No medications containing aspirin or anti-inflammatory should be taken within 15 days prior to surgery.

TYPE OF ANAESTHESIA AND HOSPITAL STAY

Type of anaesthesia:

Lipostructure breast reconstruction is usually performed under general anaesthesia, because in the same operation, several techniques can be associated and several anatomical sites are involved:

harvesting areas (buttocks, hips, abdomen or thighs, inner knees)

or the breasts.

Hospital stay:

Lipostructure alone requires a shorter hospitalization, approximately 12-24 hours. In case of associated techniques, hospitalization depends on the heaviest surgical gesture associated.

THE PROCEDURE

Each surgeon adopts his/her own technique that he/she adapts to each case in order to obtain the best results. However, we can retain some common basic principles:

The surgeon begins to make a precise location of areas of fat to be harvested, as long as the recipient sites. The choice of these areas depends on the areas of excess fat and the desires of the patient, as this harvest makes a significant improvement in the affected areas, with an actual surplus of liposuction of the fat. The choice of harvesting sites is also dependent on the amount of fat considered necessary, and on the available donor sites.

The harvest of fat tissue is done in a non-invasive way, through small incisions hidden in natural folds, using a thin suction cannula. This is followed by centrifugation for a few minutes to separate the intact fat cells, which will be grafted, from the elements that are not valid for grating (serum, oil).

The transfer of fat tissue is done through 1 to 2 mm incisions using micro-cannulas. This is done by the transfer of micro-particles of fat in different planes (from the plane of the ribs to the skin), according to many independent paths (to achieve a genuine three-dimensional network), to increase the contact area between implanted cells and tissue recipients, ensuring the best survival of grafted fat cells and therefore the "take". Overcorrection is performed, if possible, to compensate the postoperative partial reduction.

Insofar as it is a real live cell transplant (which is estimated to take 60-70% depending on the patients), the transplanted cells remain alive. Lipostructure is a definitive technique as the transplanted fat cells live as long as the tissues that are around them. However, the evolution of these fat cells is according to the adiposity of the patient (if the patient loses weight, the volume gets smaller).

The duration of the intervention depends on the number of donor sites, the amount of fat to transfer, and a possible change of position. It can vary from 1 hour to 2 hours depending on circumstances, sometimes more, if other actions are associated.

AFTER THE OPERATION: POSTOPERATIVE CARE AND FOLLOW-UP

The postoperative pain is generally moderate, but may be temporarily rather marked at the level of donor areas. Tissue swelling (edema) at the donor sites and the breasts occurs during the 48 hours after surgery, and will typically resolve in 3-4 months. Ecchymoses (bruisings) appear in the early hours in the areas of harvesting of fat: they are absorbed within 10-20 days after surgery.

A certain fatigue may be experienced for one to two weeks, especially after large fat removal and liposuction.

Sunlight or UV must be avoided in treated areas at least four weeks before, which would imply the risk of skin pigmentation. After the swelling and bruising subside, the result begins to appear within one month after surgery, but the final result requires 3-6 months.

THE RESULT

In terms of volume, it is appreciated within 3 to 6 months after surgery.

In the long-term, the positive effects on the quality of irradiated breast skin are remarkable (improved flexibility, reduction of brown stains and partially of teleangiectasias (dilated capillaries)).

The figure is also improved with the liposuction of the donor areas (hips, abdomen, thighs, knees).

The stability of the result is dependent on maintaining a stable weight.

DISAPPOINTING RESULTS

In certain difficult cases, an inadequate outcome is predictable before the procedure and a second or even third session of lipostructure may be necessary, possibly and at least 3-4 months later.

The number of sessions is not limited, except by common sense and the amounts of available fat in the donor areas.

In some cases, localized defects can be observed (although they are not real complications): localized hypocorrection, slight asymmetry, and irregularities. They are then accessible to further treatment: lipostructure under local anaesthesia, from the 6th month after surgery.

If a breast prosthesis is near the area of lipostructure, you must know that it could need to be changed, if the reinjections are near the prosthesis.

POSSIBLE COMPLICATIONS

We must distinguish here between risks related to the anaesthesia and those related to the surgery.

For the anaesthesia, the anaesthesiologist will explain the risks during the preoperative consultation. You must be aware that anaesthesia can cause unpredictable reactions, which can be difficult to control: the presence of an experienced anaesthesiologist, in a surgical context, means that the risks are statistically practically negligible. In fact techniques, products and monitoring methods have progressed considerably over the last twenty years, giving optimal safety, especially when the operation is not an emergency and the patient is in good general health.

Concerning surgery: by choosing a competent, qualified Plastic Surgeon, used to performing this procedure, you limit the risks, without however eliminating them completely.

In fact, real complications are rare after quality lipostructure: a great rigour in the indication, and in conducting the surgery is needed, to ensure in practical terms an effective and real prevention.

The infection is usually prevented by the prescription of antibiotics during surgery. In case of occurrence (rare), it will be treated with antibiotics, ice, and removing the suture next to the inflamed area. The resolution is then in about ten days, usually without significant effect on the final result.

A pneumothorax may occur exceptionally, and must be treated if important (drainage). The injury to underlying intra-thoracic organs (heart, blood vessels) is theoretically possible but has never been seen after normal practice, performed by surgeons trained in this technique.

Some harder areas (so-called fat necrosis) may occur, rarely. These zones gradually decrease in size in a few months, and slowly soften. Otherwise, in case a progressive increase you should talk to your surgeon who will decide whether to conduct further tests, usually not necessary before the annual review.

Because the deposited fat tissue remains alive, it is naturally subject to variations in weight. In case of important weight loss, the breasts can shrink. Conversely, a significant weight gain can increase the breast volume. Certain weight stability is recommended to sustain the stability of the result.

Finally, we must know that only time will bring in the certainty that such treatment can promote or cause of any breast disease.

All things considered, the risks must not be overestimated, but you must be conscious that an operation, even a minor one, always has some degree of unforeseeable unknown factors.

You can be assured that if you are operated on by a qualified Plastic Surgeon, he will have the experience and skill required to avoid these complications, or to treat them successfully if necessary.

These are the facts that we wish to bring to your attention, to complement what you were told during the consultation.

Our advice is for you to keep this document and to read it and think it over carefully after your consultation.

Once you have done this you will perhaps have further queries, or require additional information.

We are at your disposal should you wish to ask questions during your next consultation, or by telephone, or even on the day of the operation, when we will meet in any case, before the anaesthesia.


"Copyright", © "All Rights Reserved" SOFCPRE, any reproduction, even partial, of these texts is prohibited without permission from the French Society of Plastic Reconstructive and Aesthetic Surgery. A copy or reproduction by any means whatsoever, including photocopying, photography, screen capture, copy, paste, recording or otherwise, constitutes an infringement punishable under the Act of March 11, 1957 on the protection of copyright.
Authorization for reproduction of March 10, 2009, for: MCEI (www.chirurgiens-plasticiens.info).


This factsheet has been designed under the auspices of the French Society of Plastic Reconstructive and Aesthetic Surgery (SOF.CPRE) as a complement to your first consultation; to try to answer any questions you can ask yourself if you intend to use a surgical lipo-filling.

The purpose of this paper is to bring you all the information necessary and essential for you to make your decision with full knowledge of the facts. So is it advisable to read with the greatest attention.