Breast reconstruction by fat transfer

Autologous tissue reconstruction uses the patient's own tissue (there is no material other than that of her own body). These autologous tissues can be "flaps", the main ones being:

• Those on the stomach: - The TRAM: using one of the straight muscles with the skin of the stomach under the navel, transferred by turning it over at 180°, or reconnected in the armpit in microsurgery for its free form; - The DIEP: skin of the stomach without the muscle, but always connected by microsurgery.
• The back: using the large dorsal muscle and its surrounding fat, with or without skin.
  There are other flaps, of more rare use, such as the gluteus maximus muscle, the contralateral breast or a muscle from the inner thigh.
  The techniques are thus varied and allow to adapt to different situations (thin or damaged skin or volume of the breast to be reconstituted important or not…) and to the different requirements of the patients. The surgeon can thus choose the best solution to be proposed on a case-by-case basis.
  Fat transfer at the breast is currently a recognized and highly effective technique. To be performed in accordance with the proven facts of science, it must be performed in a surgical setting by a plastic surgeon or by a surgeon trained specifically for this technique. The practice of this technique outside the previously defined surgical framework is considered dangerous for patients.
  The principle of this technique is to transfer the patient's fat from a potential donor site (variable in each patient: belly, hips, thighs…) to the thoraco-mammary region where it lacks volume (localized defects, especially in the neckline, or more global defect). This technique is actually a fat graft: it means that the fat must be revascularized by the recipient medium. Reinjections are done in the pectoral muscle and under the skin for prosthetic reconstructions, or in all tissue planes for autologous reconstructions.
  In the case of breast reconstructions after total mastectomy, fat transfer is considered a surgical option both to improve tissue quality and to participate in breast volume reconstruction.
  Modern fat transfer techniques allow a harmonious distribution of fat cells, reducing the risk of oily cyst formation or poor grip (cytosteatonecrosis).
  Cytosteatonecrosis can be clinically manifested by firm, smooth, mobile, pain-free nodules in the breast. Their clinical appearance is generally characteristic. Radiologically, these fat transfers can be translated, as in any breast surgery, aesthetic or not (removal of benign or malignant tumours, breast reduction surgery, augmentation plasty…) by calcifications (related to tissue healing).
  These calcifications (macro and microcalcifications) are different from those observed in breast cancers and do not pose diagnostic problems for experienced radiologists, who can use ultrasound and MRI.
  In case of an increase in volume of swelling on the reconstructed breast, the rule must remain the same as on a native breast: in case of radiological doubt, microbiopsies will be performed.
  Currently, it can be considered that a breast lipostructure performed accordingly to the standards of a plastic surgeon experienced in this field does not cause any particular diagnostic difficulty for a radiologist experienced in breast imaging.
  Fat transfer into the reconstructed breast is often performed during a second operation, combined with other refining procedures on both breasts.

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Generally speaking, the reconstruction project is developed jointly between the patient and the surgeon, and the choice of the type of reconstruction depends on multiple factors and the patient's preference. Autologous reconstructions depend a lot on the fat "capital", estimated beforehand, and which must be stable over time (no weight variation: "find your equilibrium weight well before the operation").
As a recurrence after mastectomy is always possible, the surgeon must carry out a preoperative clinical examination to look for possible irregularities in the subcutaneous cellular tissue or skin nodules. An ultrasound of the chest wall may also be requested before the procedure to eliminate a progressive lesion. In case of doubt, a preliminary micro-biopsy will be performed. Similarly, any swelling that increases in volume at a distance from the fat transfer should be investigated by ultrasound with micro-biopsy if in doubt.
In the contralateral breast, it is currently not advisable to use this technique outside multidisciplinary teams that can ensure close and secure senological follow-up.
Once the reconstruction choice is made, the different stages of the reconstruction will be detailed, often including during the second operation, the lipostructure associated with the other elements of the second reconstruction time (reconstruction of the areola and nipple, symmetrization, liposuction of the submammary sulcus).
At the end of this consultation
• A photographic assessment is started and continued throughout the reconstruction.
• A regular preoperative check-up is carried out in accordance with the instructions.
• The anesthesiologist will be seen in consultation no later than 48 hours before the procedure.
• No medication containing aspirin or anti-inflammatory medication should be taken within 15 days of the procedure.
Type of anesthesia:
the lipostructure of the reconstructed breast is usually performed under general anesthesia because at the same time, several procedures can be associated and several anatomical sites are involved:
• the sampling areas (buttocks, hips, abdomen or saddlebags, inner side of the knees)
• the breast(s)
Hospitalization conditions:
Lipostructure alone requires a short hospital stay of about 12 to 24 hours. In the case of an associated procedure, hospitalization depends on the heaviest associated procedure.

Each surgeon adopts a technique that is unique to him/her and that he/she adapts to each case to obtain the best results. However, common basic principles can be retained:
The surgeon begins by accurately identifying the fat collection areas and recipient sites. The choice of these sampling areas depends on the areas of excess fat and the patient's wishes, because this sampling allows a significant improvement of the areas considered, by achieving a real liposuction of the excess fat. The choice of sampling sites also depends on the amount of fat deemed necessary, and the available sampling sites.
The fat tissue is removed atraumatically through small incisions hidden in the natural folds, using a thin suction cannula (a technique derived from liposuction). An "oil" centrifugation is then carried out in order to separate the intact fat cells, which will be grafted, from the elements that cannot be grafted (serosities, oil).
The transfer of fatty tissue is made from incisions of 1 to 2 mm using micro-canulas. Fat micro-particles are transferred in different levels (from the rib level to the skin) along many independent paths (realisation of a real three-dimensional network), in order to increase the contact surface between the implanted cells and the recipient tissues, which will ensure the survival of the grafted fat cells and thus the "grafting process". An overcorrection is performed, if possible, to take into account the post-operative partial resorption.
Since this is a real living cell transplant (the graft of which is estimated to be 60 to 70% depending on the patient), the transplanted cells will remain alive. Lipostructure is therefore a definitive technique since the fat cells thus grafted will live as long as the tissues around them. On the other hand, the evolution of these fat cells depends on the patient's adiposity (if the patient looses weight, the volume supplied will decrease).
The duration of the intervention depends on the number of donor sites, the amount of fat to be transferred, and a possible change of position. It can vary from 1 hour to 2 hours depending on the case, sometimes more, if other procedures are associated.

In terms of volume, it is assessed within 3 to 6 months after the intervention.
In the longer term, positive effects on the quality of irradiated breast skin are remarkable (improved flexibility, reduction in brown discolouration and partially telengiectasia (capillary dilatations).
The silhouette is also improved thanks to the liposuction of the sampling areas (hips, abdomen, saddlebags, knees).

About Breast reconstruction by fat transfer

In some difficult cases, the lack of results is predictable before the operation and a second or even a third lipostructure session may be necessary, and may be possible at least 3 to 4 months later.
The number of sessions is not limited, except by common sense, and by the quantities of available fat that can be sampled.
However, complications must be known and well understood. This is how it can be observed: skin necrosis, infection, hematoma, serous effusion, etc.
MEDICAIM organizes your entire stay for you: post-operative nursing care, biological follow-up, therapeutic, nutritional and psychological support.
Any additional questions? Ask your doctor about it: careteam@medicaim.com