Free Fat Grafting Techniques for Correction of Residual Contour Deformities after Breast Reconstruction

Michael S. Wong

Lee L. Q. Pu

Introduction

It is not uncommon to have residual contour irregularities or asymmetries between breasts after breast reconstruction, whether implant or autologous. As refinements in breast reconstruction techniques have occurred over the years, the aesthetic goals of our patients have risen. Rippling following implant reconstructions may be improved by converting a saline implant to silicone or camouflaged by use of capsular augmentation or acellular dermis. Autologous fat grafting is another technique that can improve upon these contour deformities and increase patient satisfaction with their breast reconstructions.

Background

The first use of autologous fat to replace a breast deformity was reported in 1895, when Czerny transplanted a back lipoma to replace breast tissue removed in an adenoma resection. Experience with fat injection through cannulas was described by Charles C. Miller in 1926 and liposuction in the 1980s aided in the popularization of fat as an injectable. Despite mixed results in the hands of a variety of surgeons, autologous fat grafting has grown in popularity as the demand for injectable fillers has increased.

We have adopted the Coleman technique, believing smaller amounts of fat grafts placed in multiple tunnels in multiple planes achieve the best results. We have successfully used autologous fat grafting for the correction of contour deformities of the face, upper and lower extremities, and residual deformities associated with breast reconstruction. In this chapter, we will focus on the latter, discussing preoperative planning, informed consent, surgical technique, postoperative care, and results.

Indications/Contraindications

There are numerous irregularities that may occur after total breast reconstruction, including both autologous and implant. Volume excess occasionally seen after autologous reconstructions can be successfully addressed with focused liposuction or direct excisional techniques. Irregularities secondary to volume deficiency are often improved with autologous fat grafting. The most common area of contour deformities occurs at the periphery of the reconstructed breast mound. In autologous reconstructions, this is often seen at the superior chest wall and breast mound junction, manifesting as a concavity or “shelf.” It may also occur in the areas of skin closure or flap inset. Implant reconstructions may have similar concavities amenable to improvement with fat grafting. Those women interested in a more natural appearing implant reconstruction will often desire additional volume at the superior pole to create a more gentle transition between the chest wall and the implant.

Controversy arises when one considers the use of autologous fat grafting to reconstruct the postlumpectomy deformity. Because there is a known recurrence rate associated with breast conservation therapy, any necrosis of autologous fat grafts may elicit anxiety surrounding the possibility of a recurrence. Although the spectrum of fat necrosis and postoperative changes mimicking carcinoma has been documented mammographically, the natural history of autologous fat grafts injected into the breast has not been as clearly delineated. Despite early data suggesting that calcifications following fat injection into the breast can be distinguished from carcinoma, biopsy may still be prompted by either a palpable mass or a mammographic calcification combined with patient and surgeon anxiety. Until stronger data are available and because varying degrees of calcification in breast parenchyma after autologous fat grafting is expected, our current opinion is that lumpectomy defects should generally not be reconstructed with autologous fat injections.

Preoperative Planning

Timing

Because graft take is reliant on an adequate wound bed, timing is an important consideration. We prefer to wait at least 3 months after the most recent breast surgery before proceeding with any autologous fat injections. This allows sufficient time for edema dissipation, revascularization, and stabilization of the contour deficit. Complete photographic documentation is beneficial in characterizing the three-dimensionality of the contour irregularity. We currently wait 4 to 6 months between subsequent fat injections to allow for dissipation of edema and inflammation, graft revascularization, and stabilization. We have found a three-dimensional camera to be particularly helpful in defining the volume deficit to both the patient and the surgeon.

Informed Consent

Although autologous fat grafting has been used for at least 20 years for the correction of deformities in the face, trunk, and extremities, its use in the breast has been shrouded in controversy. Much of this is based on theoretical concerns that areas of fat necrosis may mimic or conceal a breast cancer recurrence. Because of this, informed consent for autologous fat grafting to contour irregularities of the breast must be taken with particular care. Most radiologists are able to distinguish fat necrosis and postoperative changes from cancer recurrence. If there are any questions regarding the appearance of a mass after fat grafting, this should be treated as a cancer, until proven otherwise. Thus, patients must be counseled in the possibility of biopsies to rule out breast cancer recurrence. In addition, patients must understand that fat grafting is a process often involving additional grafting procedures. Again, if patients desire additional fat grafting into a previously injected area, we currently wait for 4 to 6 months between injections. This
allows sufficient time for the resolution of edema and inflammation, revascularization of graft, and the stabilization of any fat resorption.

Donor Sites

Consideration must also be given to the best donor sites. Coleman preferentially harvests from the lower abdomen and the inner thighs, believing these areas to have the easiest graft harvest. Interestingly, there is evidence that these areas have higher concentration of adipose-derived stem cells than do other areas. For patients reconstructed with implants, the lower abdomen is often available. However, for those who have had transverse rectus abdominis myocutaneous (TRAM) flap reconstructions, this is no longer available, and we then elect to harvest the inner thighs. If these areas will yield inadequate graft material, then alternate sites, such as flanks, are chosen on the basis of availability.

Surgery

Fat Graft Harvesting and Processing

Patients who elect to undergo fat grafting should not have any major systemic metabolic diseases or lipid disorders. Our preferred donor site of fat grafting is the abdomen although each inner thigh can also be selected if more fat grafts are needed (Fig. 27.1). We prefer to use the Coleman technique with some modifications for fat graft harvesting and processing because this technique is a well-described and standardized method and is used by many surgeons worldwide. Briefly, through a small incision, a mixed solution (0.5% lidocaine with 1:200,000 of epinephrine in Lactated Ringer’s solution) was infiltrated into the lower abdominal donor site or inner thigh using a blunt Lamis infiltrator (Byron Medical, Inc., Tucson, Arizona) (Fig. 27.2). The solutions are infiltrated in a ratio of 1 cc of solution per cubic centimeter of fat grafts to be harvested. The fat grafts are harvested through the same incisions made previously. The harvesting canula is 3 mm in diameter and 15 or 23 cm in length with a blunt tip (Byron Medical, Inc., Tucson, Arizona). It is connected to a 10-cc Luer-Lok syringe. Gently pulling back on the plunger of a 10-cc syringe provided a light negative pressure while the cannula is advanced and retracted through the harvested site (Fig. 27.3). After filling the syringe with harvested tissue, the cannula is removed from the syringe. A Luer-Lok plug is twisted onto the syringe to seal the Luer-Lok aperture and the plunger is removed from the barrel of the syringe and the body of the filled syringe is placed into a centrifuge (Byron Medical, Inc., Tucson, Arizona) and spun at 3000 rpm for 3 minutes (Fig. 27.4

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