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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_577_Библиотеки_им_академика_М_И_Перельмана
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A. Di Giuseppe and F. Giovagnoli
Fig. 24.43 48-year-old patient, mild breast asymmetry, fat transfer to breast, fat harvested from anks, outer and inner thighs and torso
24 Breast Fat Augmentation. Step-by-Step Technique andUltrasound Assisted Liposuction for Contouring ofDonor Area
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Fig. 24.44 35-year-old patient, mild breast asymmetry, fat transfer to breast, fat harvested from anks, outer and inner thighs and torso
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A. Di Giuseppe and F. Giovagnoli
Fig. 24.45 35-year-old patient, mild breast asymmetry, fat transfer to breast, fat harvested from anks, outer and inner thighs and torso
24 Breast Fat Augmentation. Step-by-Step Technique andUltrasound Assisted Liposuction for Contouring ofDonor Area
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References
1. Panetta NJ, et al. Tissue harvest by means of suction-assisted or
third-generation ultrasound-assisted lipoaspiration has no effect on
osteogenic potential of human adipose-derived stromal cells. Plast
Reconstr Surg. 2009;124:65.
2. Vilaboa S, Llull R, Mendel TA.Returning fat grafts to physiologic
conditions using washing. Plast Reconstr Surg. 2013;132:323e.
3. Mestak O, et al. Centrifugation versus Puregraft for fat grafting
to the breast after breast-conserving therapy. World J Surg Oncol.
2014;12:178.
4. Hanson SE, Garvey PB, Chang EI, Reece G, Liu J, Butler CE.A
prospective pilot study comparing rate of processing techniques in
autologous fat grafting. Aesthet Surg J. 2019;39(3):331–7.
5. Shiffman MA, Di Giuseppe A, Bassetto F. Stem cell in aesthetic
procedures, art, science and clinical techniques. Springer; 2014.
6. REVOLVE Advanced Adipose System by LifeCell AbbVie.
Instructions for use 2017.
7. Dos-Anjos Vilaboa S, Llull R, Mendel TA. Returning fat grafts
to physiologic conditions using washing. Plast Reconstr Surg.
2013;132:323e–6e.
8. Dos-Anjos Vilaboa S, Navarro-Palou M, Llull R.Age inuence on
stromal vascular fraction cell yield obtained from human lipoaspirates. Cytotherapy. 2014;16:1092–7.
9. Bircoll M.Autologous fat transplantation: an evaluation of microcalcication and fat cell survivability following (AFT) cosmetic
breast augmentation. Am J Cosmet Surg. 1988;5:283.
10. Levenberg A, Scheinowitz M, Sharabani-Yosef O.Higher cell viability and enhanced sample quality following laser-assisted liposuction versus mechanical liposuction. J Cosmet Dermatol Sci Appl.
2015;5:238–45.
Postmastectomy Total Breast
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Reconstruction by Serial Lipografting
PietroBerrino andValeriaBerrino
Contents
25.1 Introduction 355
25.2 Total Breast Reconstruction by Fat Grafting in Group 1 Women 356
25.3 Total Breast Reconstruction in Group 2 Women 359
25.4 Final Considerations 362
References 363
25
25.1 Introduction
Fat transfer is currently widely used in breast reconstructive
surgery for the treatment of tissue damage after radiation
therapy [1], for site preparation before alloplastic reconstruction [2], for correction of contour irregularities after reconstruction using implants [3], for correction of defects
conservative surgery [4, 5], and for renements after autologous tissue reconstruction. Its use in total breast reconstruction after mastectomy is still limited because lipografting
can only provide volume, but it cannot stretch the skin at the
mastectomy site.
Candidates to total breast reconstruction by fat injection
can be divided into two different groups:
Group 1: Women with preserved submammary fold and
relaxed mastectomy site skin can obtain projection and ptosis by simple multiple fat injections. The presence of an
untouched submammary fold is crucial because the skin
above the fold is mammary skin, which is thinner, more pliable, and expandable than thoracic skin. The mammary skin
lled by fat grafting stretches forward and bends over the
preserved submammary crease, thus creating a fold and a
natural looking breast.
Group 2: In these patients, the submammary fold has been
violated and moved upward during the mastectomy procedure. The thoracic skin is stretched to the mastectomy scar.
P. Berrino (*) · V. Berrino (*)
Chirurgia Plastica srl, Genoa, Italy
Lipolling under the thick inelastic thoracic skin produces a
fat chest wall, but cannot provide the projecting shape of a
new breast. In this group of patients, therefore, expansion is
needed in order to:
– Stretch the thoracic skin forward
– Change the thick thoracic skin into a thinner, more pli-
able, and complying envelope, suitable for lipolling
– Create a new submammary fold in the proper position
Mastectomy site skin in Group 2 women can be expanded
by external or internal expansion.
External expansion was described by Khouri and Rigotti
[6] and Khouri and Del Vecchio [7, 8] who used serial lipografting to create a breast mound in patients who were preliminarily treated by external expansion using the BRAVA
System (BRAVA Inc., Miami, FLO). The use of external
expansion devices according to the manufacturer’s protocol
[9] led to a 28% withdrawal rate because of social embarrassment, discomfort, difculties in wearing the device at
night, and insomnia [10]. The external expander device
appears to show poor compliance in postmastecomy patients
due to the long and difcult pre- and postoperative period of
external expansion.
In 2008 at the 19th Euraps Meeting, we rst reported the
use of internal expansion and serial lipografting, naming it
“the REAL (Reverse Expansion And Lipolling) technique”
[11]. This presentation was awarded as “best paper” of the
Meeting. Since 2007 we reported the procedure in several
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_25
355
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P. Berrino and V. Berrino
Meetings, and it has become a popular procedure, although
reserved to a small subgroup of candidates [12, 13].
Selection of the candidates on the basis of the individual
psychological attitude is as much important as correct assessment of the physical characteristics. The classication we have
proposed for psychological assessment of the postmastectomy
patients [14] proved to be crucial for the selection of the right
candidate to total breast reconstruction by fat grafting.
Type 1 patients are highly motivated women who are willing to accept major operations in order to recover the body
image they had before the mastectomy: typically they are
candidates to autogenous tissue reconstruction by the
abdominal ap. Type 2 women are more sophisticated highly
demanding patients who have considered aesthetic surgery
before mastectomy and badly accept additional scarring and
multistage procedures. Typically, the choice for this group of
woman is implant reconstruction with contralateral mammoplasty. Type 3 women are those who do not wish to undergo
major procedures—and related complications—and prefer
to undergo multistage minor procedures not affecting their
social and family life. These women are typical candidates to
total breast reconstruction by fat grafting.
25.2 Total Breast Reconstruction by Fat
Grafting inGroup 1 Women
Group 1 women show an untouched submammary fold and
abundant skin above it. This condition can be seen after skinsparing or nipple-sparing mastectomy in patients who did not
receive an implant or who had the implant removed due to secondary complications. This group of patients does not generally
include women who received radiation therapy, but RT is not by
itself a contraindication to the procedure unless severe skin
damage is present. Fat injections, in facts, often produce an
amazing improvement in the quality of the radiated skin and can
change a stiff skin area into a pliable, elastic skin envelope.
Some of these patients may require scar revision and release due
to scarred retracted areas that can jeopardize skin compliance.
Contraindications to the procedure are:
– Severely scarred or radiation damaged skin at the mastec-
tomy site
– Insufcient fat deposits at the donor sites
– Patients unwilling to undergo multiple procedures or to
accept a long period for completion of the reconstruction
– Patients with large contralateral breast unwilling to
undergo reduction
Ambulatory lipolling sessions are scheduled at about
3-month intervals, and they are carried out under sedation
and local inltration. The donor site is inltrated with modied Klein solution (for each 500cc of saline solution, 1cc
adrenaline, 12cc xylocaine 2%, 2cc sodium bicarbonate).
Adipose tissue is suctioned using a 2.5mm (inner diameter) cannula and a 10cc Luer-lock syringe. The preferred
donor sites are the anks, lateral upper thighs, and inner
knees. We prefer to avoid the abdomen as a donor site due
to the high risk of skin irregularities and long-term skin
emptiness.
Separation of fat and uids is obtained by simple decantation. A 10-min period is sufcient for separation of fat from
uids and oil. The aspirated fat is transferred into 2.5mL
Luer-lock syringes. After inltration of the recipient site
with the described modied Klein solution, the fat is slowly
injected on withdrawal of the plunger using 2 or 1.5 mm
(inner diameter) cannulas, so as to release a fraction of milliliter at each passage. Fat is transplanted over the pectoralis
major muscle and in the subdermal space, according to the
principle of bicompartmental lipostructure described by
Zocchi for breast augmentation [15].
Fat dispersion into healthy subcutaneous layers is crucial
in order to obtain a satisfactory graft take. In spite of accurate
fat dispersion, 12–15 mL of aspirate per minute can be
injected, so that 200 mL are injected in about 15 min and
each lipostructure session is completed in approximately
40min.
During fat grafting sessions, contralateral mammoplasty
can be performed, and local release of scarred tissue is also
accomplished when needed. Nipple-areola reconstructions
and nal touch-ups are carried out during the last surgical
stage.
Each patient has a clinical and photographical evaluation
at 1 and 3months after each surgical procedure and at 1, 3, 6,
and 12months after the last operation.
In our series, all Group 1 patients who completed the
scheduled sessions showed good to excellent results except
one woman who had a cranially displaced submammary
fold which could not be repositioned by lipostructure
alone. This woman was erroneously included in Group 1;
she was actually a Group 2 patient with a dislocated submammary fold needing internal expansion. Almost all
patients show oil cysts on sonography evaluation at the
1-year follow-up and no suspicious breast lump was
observed [12]. Volume reduction of the fat graft occurring
after each session was estimated to be approximately 30%
at the 4-month follow- up. Volume appeared to be stable
after 4 months, and long- term follow-ups after the nal
grafting session showed minimal fat resorption. Only a
minority (approximately 15%) of patients requested further fat injection after more than 1year from the nal operative session.
25 Postmastectomy Total Breast Reconstruction by Serial Lipografting
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25.2.1 Clinical Examples
25.2.1.2 Case 2
A 51-year-old woman presented for left side implant removal
25.2.1.1 Case 1
A 51-year-old woman presented for breast reconstruction
after mastectomy. The submammary fold was preserved,
skin was not tight, and the contralateral breast was small and
showed minor glandular ptosis (Fig.25.1a, b). Three lipografting sessions were carried out and 200mL of aspirated
fat were injected at each session (Fig.25.1c, d). During the
third session, contralateral periareolar mastopexy was carries
out, and NAC reconstruction by contralateral grafts was performed (Fig.25.1e, f).
after nipple sparing mastectomy. She had chronic infection
with drainage that had been treated conservatively for more
than 12 months. She had developed severe scar retraction
around the NAC.Contralaterally, she had a ptotic augmented
breast (Fig.25.2a). She was affected by multiple sclerosis,
and she preferred to avoid major surgery under general
anesthesia. The left infected implant was removed with relief
of symptoms. The right implant was also removed (Fig.25.2b,
c). Four lipografting sessions were planned. Twenty days
after the rst lipostructure session, she showed healing of the
abc
def
Fig. 25.1 Front (a) and lateral (b) view of a 51-year-old. Group 1
woman after total mastectomy, showing preserved submammary fold;
front (c) and lateral (d) view after 2 lipolling sessions, before right
periareolar pexy, nipple/areola reconstruction by contralateral grafts,
and nal fat grafting; front (e) and lateral (f) view after the last operative stage
358
ab c
gi
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de f
P. Berrino and V. Berrino
h
Fig. 25.2 Front view (a) of a 52-year-old woman, 2 years after left
nipple sparing mastectomy and right periareolar pexy with subglandular
implant positioning. A draining stula from the left implant pocket to the
periareolar scar is present since 1year. Front (b) and lateral (c) view
after bilateral implant removal and healing of the stula. Front view (d)
after the rst session of lipografting and scar release on the left side.
Right vertical mastopexy is planned and further scar release and fat
grafting on the left side is planned. Front view before the third lipografting session (e). Front view before the fourth surgical session (f). Front
view 40days after the last session (g). Eleven months after the last session: complete release of the scarred tissue is observed (h). Nineteen
months after the last fat grafting sessions the result is maintained (i)
25 Postmastectomy Total Breast Reconstruction by Serial Lipografting
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359
periareolar stulas. Revisions of the retracted scar and contralateral pexy were also carried out during lipografting sessions (Fig.25.2d–f). All session were performed under local
anesthesia and sedation. Full-volume restoration was
obtained, and total release of the severely scarred and
retracted tissue was achieved (Fig.25.2g–i).
25.3 Total Breast Reconstruction inGroup
2 Women
Group 2 women show violated inframammary fold. The
abdominal skin is stretched cranially and reaches the mammary skin at the mastectomy scar. These patients obviously
show various degrees of skin tightness and thickness; the
pectoralis major muscle can be damaged or absent. Group 2
women can be selected to undergo breast reconstruction by
internal expansion and serial lipografting according to the
following inclusion criteria:
• Adequate adipose tissue reserve (based on regional fat
deposits and on the volume to restore)
• Skin thickness of more than 1.5 cm at the recipient site,
evaluated with the pinch test
• Absence of skin tension, severe scarring or RT damage at
the mastectomy site
• Willingness to accept multistage procedure and to avoid
the use of permanent implants
From a psychological point of view, the candidate for
“REAL technique” is the patient that we have categorized as
“type 3” in terms of expectations and psychological attitude
[14]: a woman who is not willing to accept major procedures
and associated possible complications, who is not willing to
undergo long hospitalization and who expects a reasonable
result through minor and well tolerated operations.
In patients who have an expander positioned during the
mastectomy operation serial lipoinjections with expander
deation can be started. In patients who do not already have
an expander, an expandable implant is positioned during the
rst operation. The lower border of the expander is positioned at or slightly below the future submammary fold. The
expander is positioned submuscularly if the pectoralis major
muscle is present. Lipografting is carried out into the subcutaneous layer and into the prepectoral fat layer (or above the
chest wall if the muscle is not present). According to the
inclusion criteria, thickness of the subcutaneous layer above
the expander is at least 1.5cm allowing appropriate fat graft
dispersion. The technique for fat harvesting and injection is
identical to that described for Group 1 patients. During the
rst session, after positioning the expander, 200–250mL of
aspirated fat is usually injected in the subdermal plane, so as
the graft is not dispersed into the implant pocket. In the next
8–10 weeks after the rst session, the expander is slowly
inated to the expected nal volume. Care is taken not to
create skin tension above the expander, in order to avoid fat
compression and atrophy. After reaching the nal expected
volume, serial fat grafting is scheduled.
Three to ve sessions of fat injection are planned, based
on the volume to restore.
At each session, the expander is partially deated by 100–
250mL, and the subcutaneous layer is grafted with aspirated
fat. The volume of the fat graft injected in each session
exceeds the milliliters of saline taken out from the expander
by approx. one-third (e.g., if the expander is deated by
200mL, 260mL of aspirate are injected). The amount of fat
grafted at each session exceeds the desired volume by
25–30% because an approximate 30% volume loss after each
procedure is to be expected.
Sessions are scheduled at about 3-month intervals.
Contralateral adjustments are performed, if needed, during
one of the fat grafting procedures.
During the last session, the expander is removed, nippleareola complex reconstruction is usually performed, and
nal touch-ups are carried out.
Each patient has a clinical and photographical evaluation
at 1 and 3months after each surgical procedure and at 1, 3, 6,
and 12months after the last intervention.
All sessions are carried out under sedation and local inltration of the already described modied Klein solution.
Sessions requiring expander implantation and contralateral
mammoplasty are performed under general anesthesia.
Fifteen percent of Group 2 patients selected for the REAL
technique wished to interrupt the lipolling schedule and to
have the expander replaced by an anatomical permanent
implant. These patients were nally given a “hybrid” reconstruction as described by Nava [16]. All the patients who completed the scheduled sessions showed good to excellent results.
Patients frequently showed minute oil cysts at sonographic evaluation at the 1-year follow-up.
As reported for Group 1 patients, approximately 30% of
the grafted volume was lost in a 4-month period, while volume remained stable thereafter. Approximately 20% of the
patient who underwent the REAL technique requested additional fat injections after 3–10years from the last scheduled
session.
25.3.1 Clinical Examples
25.3.1.1 Case 3
A 54-year-old woman presented after right modied radical
mastectomy (Fig.25.3a, b). She also showed a remarkable
presternal contour defect due to pectus excavatum (PE)
deformity. Two lipostructure sessions were preliminarily
carried out in order to correct the PE deformity (Fig.25.3c).
Three months after PE correction, a 450 cc breast
expander (Siltex Contour Prole-Mentor Medical) was posi-
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abc
P. Berrino and V. Berrino
d
ef
g
h
Fig. 25.3 Front (a) and lateral (b) view of a 54-year-old woman show-
ing Pectus Excavatum deformity and right radical mastectomy. Front
view (c) after correction of the Pectus Excavatum by two lipografting
sessions; further presternal fat injection and expander positioning is
planned. Intraoperative view (d) showing immediate subdermal fat
injection after placement of the expander: the lower quadrants are
mainly grafted. Front view (e) after the rst lipografting session:
implant deation and lipografting is planned. Front view (f) after three
REAL sessions, before the nal stage: nipple/areola reconstruction, further lipografting and implant removal are planned. The outcome is
shown 3months (g) and 3years (h) after the nal surgical stage
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