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combined with clinical expertise, the evidence provided in
this chapter will help plastic surgeons better counsel and
educate patients to achieve reproducible and predictable
aesthetic outcomes.
Patient Selection
Preoperative History and Information
Breast conservation and AFG should only be performed
after full informed consent, primarily because this is a novel
investigative technique. Although most clinical studies to
date have demonstrated this to be eective, the majority
are retrospective with a low level of evidence. e initial
consultation should clarify the patient’s medical history and
expectations. Each patient is informed in detail about the
technical aspects, advantages, disadvantages, and potential
early and late complications. In our practice, we emphasize
three main aspects: the possibility of fat resorption, multiple
fat grafting procedures may be necessary, and that aesthetic
outcome will vary with changes in body weight. It is crucial
to discuss the risk of local recurrence and discuss studies
that have demonstrated that local recurrence has not been
linked to AFG. Although complications in the donor area
are infrequent, the patient must be advised that ecchymosis,
hematoma, prolonged swelling, and minimal scarring may
occur.
Patient Evaluation and Considerations
Before AFG, all patients should undergo ultrasound, mammogram, and breast magnetic resonance imaging (MRI).
Following AFG, patients should have breast ultrasound
and mammogram 6 months after the nal AFG procedure.
Before surgery, an accurate physical examination is performed with the patient in a standing position. e canceraected breast is compared with the contralateral breast
for planning in the regions requiring repair. It is important
to evaluate symmetry, shape, volume, the position of the
nipple–areolar complex (NAC), and the presence of local
radiotherapy (RT) eects including brosis and retractile
scars. Physical examination and manipulation of the entire
breast and the quadrant area permits calculation of the volume of fat that needs to be harvested as well as planning for
associated procedures like percutaneous fasciotomies and
contralateral symmetrization. e abdomen is usually the
preferred donor site because it does not require changes in
patient position and tends to contain an adequate volume of
fat. An alternative choice is the outer or inner thigh.
Indications and Contraindications
Indications and Timing
In patients having immediate reconstruction, the surgical
process is facilitated because the ablative and reconstructive procedures occur in the same operative setting. Because
there is no scar or brosis at the initial operation, breast
reshaping is simplied and the aesthetic outcome is usually
improved.
6,7
Kronowitz et al demonstrated that immediate repair following partial mastectomy is preferable over a
delayed procedure because the incidence of complications is
usually decreased.6 Our experience has demonstrated that
the complication rate following radiation (for delayed BCS
reconstruction) is higher when compared with reconstruction without RT.
16,17
Clinical studies have demonstrated
that patients with larger breasts present more radiationrelated complications than patients with breasts of normal
volume.
7,18
Another point is that immediate reconstruction
permits wider local tumor excision and may reduce the incidence of margin involvement.
7,19
Despite the benets of the immediate approach, there
are also limitations. e surgical time may be longer, and
specialist training is required to learn and properly apply
these procedures.
11,17
As a result, for some specic patient
groups, delayed reconstruction should be considered. Radiation is known to generally result in some degree of breast
brosis, and in some cases the nal breast contour cannot
be predicted at the time of the initial BCS.17 e delayed
approach allows the plastic surgeon to wait until the postoperative changes in the deformed breast stabilize. Our experience has demonstrated that there is insucient space for
AFG in most cases of immediate reconstruction primarily
because the skin aps have been undermined compromising
the inltration of fat.
Despite these limitations, studies have described immediate BCS reconstruction through AFG injection into the
tissues beyond the margins of the wide excision site.
9,13,15
Khan etal evaluated the aesthetic outcomes of patients after
BCS and immediate AFG reconstruction compared with
BCS alone.9 In a series of 71 patients with median followup of 36 months, the authors demonstrated signicantly
better aesthetic results from AFG (p < 0.001) and fewer
local breast symptoms (p = 0.0045) compared with the BCS
only group. Other authors performing studies without a
comparison group also observed satisfactory outcomes following immediate AFG reconstruction.
13,15
Contraindications and Limitations
ere are no formal contraindications to AFG as an adjunct
to oncoplastic reconstruction. Ideal candidates are at normal weight or overweight and have small to moderate breast
defects. in patients are sometimes challenging because of
the lack of sucient fat donor sites; however, adequate volumes of fat can often be harvested from the hip and ank
regions.20 It is important to emphasize that an additional
70% of the volume of fat needed to reconstruct the BCS
must be harvested to compensate for the portion of fat lost
during decantation/ltration process (Table 14.1).
Autologous fat grafting following RT can be challenging
due to the eects of radiation that include skin retraction,
severe brosis, and distortion of the NAC. In some situations, and depending of the severity of the deformity, AFG
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TABLE
Indications and Contraindications of Breast
14.1
Conservative Surgery Reconstruction with
Autogenous Fat Grafting
Indications Contraindications
• Small/moderate breast
defects
• Normal weight/overweight patients
• Well informed/realistic
expectations
• Normal baseline image
breast exams (mammogram, ultrasound and
MRI)
MRI, Magnetic ressonance imaging;
(*)
, relative contraindication.
• Large breast defects/
severe deformities
• Thin patients/previous
liposuction (*)
• Unrealistic expectations
• Absence of previous
breast exams/suspicious
breast lesions
is not an adequate technique, and several procedures may
be required. Additionally, the tissues in irradiated areas lack
elasticity that can limit the volume of fat that can be injected.
In this scenario, the patient should be informed that a 4–6
month interval between procedures is recommended. When
the radiation changes are severe, alternative strategies such
as local or distant aps should be considered. Mastectomy is
sometimes the best option in refractory cases.
Operative Approach
Breast Defect Classification
Several classication schemes have been developed to
dene breast deformities and proposed reconstructive tech-
2,5-7
niques.
reshaping, and local and distant aps. e role of AFG is
sometimes omitted from these strategies based on the tissue
decit and the presence of RT eects. Most articles include
these options within a broader category of complex breast
defects with few clinical studies having been published that
propose an algorithm for reconstruction.
Our 20 years of experience with oncoplastic surgery has
enabled us to identify various patterns of acquired breast
deformities and develop an algorithm for immediate and
delayed BCS reconstruction based on initial breast volume,
the extent/location of glandular tissue resection, and the
remaining available breast tissue.7 Each defect is unique and
has its own specic reconstructive requirement to achieve a
desired aesthetic outcome. With this in mind, partial breast
defects can be classied into one of three types (Fig. 14.1):
Type I: Defects include resection in a smaller breast without ptosis. Type IA defects involve minimal defects that do
not cause volume distortion, with resected tissue accounting
for less than 10–15% of total breast volume. Type IB defects
involve moderate defects that generate moderate volume
distortion, and resected tissue is between 15–40% of total
ese strategies involve primary closure, breast
volume. Type IC defects are large and cause signicant volume distortion, with resected tissue comprising more than
40% of total breast volume.
Type II: is group includes tissue resection in medium-
sized breasts with/without ptosis. Type IIA involves small
defects that do not cause signicant volume distortion. Type
IIB defects are moderate and cause minor/moderate volume
alteration. Type IIC defects cause moderate/large volume
variations in the breast shape.
Type III: is group includes tissue resection in large
breasts with ptosis. Type IIIA defects are small and do not
cause signicant aesthetic deformity. Type IIIB involves
moderate defects leading to minor/moderate volume alterations. Type IIIC defects are large and cause signicant volume alteration (Scheme 14.1).
Operative Techniques: Classic Oncoplastic
Procedures and AFG
eoretically, most oncoplastic techniques can be associated with AFG as a complement or surgical renement.
Surgical planning should include the breast volume, tumor
location, extent of glandular tissue resected, and should
especially address individual reconstructive requirements,
providing an individualized reconstruction tailored to
each patient. Evaluation of BCS reconstruction must subsequently consider these important points, and only then
should the proper technique or a combination of procedures
(AFG+mammaplasty, AFG+local aps, etc.) be chosen. In
our experience, most reconstruction techniques incorporate one of six surgical options: breast tissue advancement
aps (BAF), lateral thoracodorsal aps (LTDF), bilateral
mastopexy (BM), bilateral reduction mammaplasty (BRM),
latissimus dorsi myocutaneous aps (LDMF), and lateral/
anterior intercostal perforator aps (AICAP, LICAP).
Types IA, IIA, and IIIA: Repairs generally include BAF
when the defect is spherical or rectangular. e breast tissue
is advanced along the chest wall or beneath the breast skin
ap to ll the tumor defect. To achieve a better aesthetic
outcome without signicant skin retraction, supercial
undermining can be performed between the breast tissue
and skin ap, preserving the skin blood supply. Usually no
contralateral breast surgery is required in these patients. In
both immediate and delayed reconstructions, AFG can be
indicated as a complementary procedure. e major limitation of AFG is related to the degree of retraction and local
brosis, a fact that can determine the need for serial percutaneous fasciotomies and multiple surgical procedures.
Patients with skin laxity, no previous RT (rarely observed,
except in benign cases), and no brosis can be treated in one
or two stages. In patients with moderate brosis and local
RT eects, external expansion, and more surgical steps with
serial percutaneous fasciotomies may be necessary to achieve
a satisfactory result.
22-25
Type IB: In patients with lateral defects, LTDF can
be indicated. As described elsewhere,26 this local ap is
planned as a wedge-shaped triangle located entirely on the
7,21
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A
C
B
D
• Fig. 14.1 AFG harvesting technique. Following injection of local anesthesia (40–100 cc/area of 1% lido-
caine + 1:80,000 epinephrine) (A), fat is harvested using a blunt 3-mm cannula connected to a 60-cc
syringe (Byron Medical, Inc., Tucson, AZ, USA.) (B, C). We do not use mechanical aspiration to reduce the
surgical trauma on the AFG (D).
Small defects
without distortion
Moderate defect,
moderate distortion
Scheme 14.1 Trends in types of breast defects and an algorithm for immediate and delayed BCS reconstruction on the basis of the initial breast volume, the extent/location of glandular tissue resection, and the
remaining available breast tissue.
I. Small volume
without ptosis,
cup size - A,B
II. Medium volume
with or without ptosis,
cup size - C
III. Large volume
with ptosis,
cup size - D
A B C A B C A B C
Large defects,
severe distortion
Small defects
without distortion
small to moderate
7
Moderate defect,
distortion
moderate to severe
without distortion
Large defect,
distortion
Small defect
Moderate defect,
small distortion
Severe defect,
moderate to severe
distortion
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lateral aspect of the thorax and then rotated to the lateral
breast defect. Although additional scars are necessary, these
are placed in the lateral region with a satisfactory outcome.
In very thin patients who do not have sucient volume in
the ap area, AFG can be performed to increase ap volume. In this situation, care should be taken with the volume
injected to avoid ischemia of the ap and loss of results. In
patients with central and medial tumors, LDMF27 or lateral
and anterior intercostal perforator aps (AICAP, LICAP)21
can be indicated. Local aps and especially LTDF are useful techniques for upper outer or lower outer defects. Using
tissue located adjacent to the defect provides matching
color and texture for the breast, and when this technique is
associated with AFG large volumes can be achieved. In our
practice we have used LDMF to replace skin and glandular
tissue resected during oncologic surgery.27 is is frequently
indicated for severe defects where there is not enough breast
tissue to perform the reconstruction. As with LTDF aps,
AFG can be performed carefully to increase the volume
of the ap and optimize reconstruction. e LDMF ap
provides the possibility of intramuscular fat grafting, which
permits safer transfer of a larger volume of fat than nonmuscular aps (LTDF and perforator aps).
28
Type IC: Defects are converted to a skin-sparing mastectomy (SSM) and reconstructed with an appropriate
technique. AFG can be indicated as a complement for
total reconstruction with alloplastic tissue (expanders and
implants) or renement for autogenous tissue (abdominal
7
aps).
Type IIB: Defects are frequently reconstructed with BM
techniques when there is sucient breast tissue to perform
the reconstruction. e preoperative appearance can be
improved with smaller and more proportional breasts.
16,17
is technique facilitates radiation therapy in the remaining
breast tissues with acceptably low complication rates.
16-18
Surgery is usually performed on the opposite breast to obtain
appropriate symmetry, particularly in breasts with severe
ptosis. With a well-trained surgical team, the procedure
can take place simultaneously on both sides, consequently
reducing operative time. AFG can usually be indicated to
rene BM reconstruction to treat tissue irregularities frequently observed after adjuvant RT treatment. Mild cases
may require only percutaneous fasciotomies and AFG can
be performed22; in more severe cases, previous expansion
(using the Brava system), serial percutaneous fasciotomies,
and several surgical stages may be necessary.
22-25
Type IIC: Defects are analyzed individually according
to the size of the breast defect in relation to the remaining breast tissue available. During evaluation, the patient is
positioned upright to assess the amount of remaining glandular tissue. Type IIC can be subclassied into favorable
and unfavorable defects; if there is enough tissue to create
an adequate breast mound, the defect is classied as favorable. For lateral defects, extended LTDF or LTDF associated with AFG may be indicated. In patients with central
and medial defects, extended LDMF or perforator aps can
be indicated. When insucient breast tissue remains, the
breast defect is classied as unfavorable and SSM and total
reconstruction are indicated, and AFG may be indicated as
a complement to total reconstruction.
7
Type IIIB: Defects are frequently reconstructed with
BRM techniques. e most favorable tumor location is in
the lower breast pole, where a conventional superior pedicle
or superior-medial technique can be utilized. In patients
with central tumors, an inferior pedicle is used to carry
parenchyma and skin into the central defect.
16
Type IIIC: Breast defects are analyzed individually. When
the defect is favorable the deciency is most frequently
reconstructed with BRM. Marked reshaping of the breast
with available tissue and similar contralateral breast reduction are then performed. In patients with an unfavorable
relation, SSM and total breast reconstruction with an
appropriate technique can be indicated. As mentioned for
Types IC and IIC, AFG can be performed to rene total
reconstruction with alloplastic or autogenous tissue.
Operative Techniques: AFG Procedure
AFG is extensively used in reconstructive surgery to restore
volume and contour defects with technical variations on fat
harvesting, preparation, and grafting.
surgical procedures have been described, including washing,
centrifugation, decantation, and previous expansion, there
is still discussion on intake, outcome, complications, and
long-term results.
29-32
Debate also continues not only on
the optimal AFG technique but also the preparation regime
for the recipient site.
10,24
Some authors advocate the preoperative use of negative-pressure systems
gressive external breast skin expansion results in increased
local vascularization, less pressure, and more free space for
AFG. Mirzabeigi etal evaluated safety and outcomes following external expansion of the breast and AFG following BCS in a series of 27 AFG sessions on 20 patients with
mean follow-up of 2.3 years.33 ese authors found no cases
of local relapse following AFG and no dierence in complication rates between patients where the external expansion was and was not used. External expansion permitted a
signicantly greater initial ll volume than those that were
not externally expanded (219 mL vs 51 mL). Despite these
results, other authors have demonstrated that one or two
AFG sessions were sucient to obtain a satisfactory outcome
in most patients following BCS reconstruction without
previous external expansion.10 As of this writing, no comparative controlled randomized study has made a detailed
comparison of AFG with previous external expansion and
AFG alone. Furthermore, there are limited clinical data
indicating the use of external negative-pressure systems for
treatment of BCS defects, and consequently more research
is needed on the role of the external expansion, local eects
of negative pressure, and whether this therapy has an eect
on angiogenic stimulation and cell proliferation.
As for harvesting and preparation in AFG, Coleman and
Saboeiro introduced the “structural fat grafting” concept and
pointed out the relevance of extracting nonviable aspirate
29-32
Although various
23,25,33
; basically, pro-
33
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components by centrifugation.34 e present technique has
gained clinical application and has become important in a
variety of procedures described in many other studies.
29-31
Although it is currently our preferred technique (Colemanmodied associated with closed systems), this procedure
is controversial in the literature.
29-31
Khater etal observed
that more active preadipocytes were maintained in noncentrifuged adipose tissue, which could potentially lead to
enhanced fat survival.35 Similarly, Rohrich etal performed
a quantitative analysis of the role of centrifugation and harvest site and found that the fat survival rate after centrifugation was no better than after ltration.
36
Several fat-processing techniques have recently become
available to boost the predictability of AFG. Some of the
new procedures oer much faster fat processing, which is
especially productive for large-volume fat grafting. One
such system uses the PureGraft device (Cytori erapeutics,
San Diego, CA, USA), which involves washing and ltering
the fat to prepare the grafts.
37,38
AFG Technique
e AFG procedure applied after BCS reconstruction is
derived from the technique applied for total breast reconstruction and aesthetic breast augmentation.20 We usually
begin by identifying the best donor site areas, which are
marked before the procedure with the patient in an upright
position. Possible donor sites include the abdomen, anks,
inner thigh, trochanteric region, and distal thigh. For most
patients, the abdominal wall serves as the preferred donor
site followed by the lateral thigh and ank regions. Abdominal fat is harvested through a single periumbilical and
suprapubic incision, whereas suprailiac incisions are used
for the ank (one on each side) and trochanteric area. We
use a modied Coleman technique for AFG harvesting.34
Following injection of local anesthesia (40–00 cc/area of
1% lidocaine and 1:80,000 epinephrine), fat is harvested
using a blunt 3-mm cannula connected to a 60-cc syringe
(Byron Medical, Inc., Tucson, AZ, USA). To reduce the
surgical trauma involved in AFG, mechanical aspiration is
not used (see Fig. 14.1). Since 2016, our practice has been
using closed fat ltration systems such as PureGraft (Cytori
erapeutics, San Diego, CA, USA), which is thought to
have some advantages over simple decantation or centrifu-
37,38
gation.
contamination and possible infection. e second advantage
is that processing time is accelerated as only about 10 minutes are needed to obtain 300 cm3 of AFG. After this step,
the puried fat is transferred into 3-cc syringes for injection
through blunt cannulas. Strict sterility is maintained, and
prolonged exposure to air is avoided throughout the entire
process (Fig. 14.2). Two to four small incisions are made in
each breast, and the fat is injected into the subcutaneous tissue near the defect area of the ap. We suggest using a 3.0-cc
syringe connected to a 1.9–2.1-mm cannula, which allows
the controlled precision necessary to graft 0.1–0.5 cc of fat
per centimeter of cannula movement. In our experience,
First, it is a closed system, which avoids graft
large cannulas and syringes do not provide the necessary precision for this maneuver. e AFG technique relies on preoperative topographic markings, grafting small amounts of
fat through multiple passes along several planes from deep to
subcutaneous tissue; this process requires use of blunt cannulas in the subdermal region. In some cases, a blunt cannula is
utilized before this stage, depending on the degree of brous
tissue observed (Fig. 14.3). e fat is slowly injected with a
retrograde technique in small volumes without putting too
much pressure on the syringes, following the principle of the
“spaghetti” technique. We always avoid overlling in AFG
to limit ischemia and necrosis. With this in mind, care must
be taken in cases with severe brosis associated with the local
eects of RT, which result in noncompliant, hard tissue with
limited distensibility (Scheme 14.2). In these cases, as the fat
is grafted the tissue compliance becomes tense, and smaller
volumes of fat can lead to a major increase in pressure. is is
very important, because injecting too much fat (“fat lakes”)
into one small region can result in ischemia because the
revascularization is insucient for large-volume fragments.
In patients who have previously undergone RT, BCS defects
are generally much less compliant and much less tolerant of
large volumes of AFG. erefore, to improve vascularization
and AFG intake, we strongly recommend that fat be spread
carefully as a ne mist of small droplets using the sprinkler
principle, avoiding higher tissue pressure (Scheme 14.3). If
necessary, percutaneous aponeurectomy with an 18-gauge
needle can be an important way of releasing scar tissue. Care
must be taken to avoid wide subcutaneous undermining during percutaneous aponeurectomy. e goal of this maneuver
is to create a mesh-like pattern within the brous tissue and
not to create an open space or lake-like eect. After the fat
injection, the injected area is carefully reshaped to adapt to
the outline of the desired surface (Figs. 14.4 and 14.5).
Outcome
Results following AFG have been very acceptable with
low complication rates; however, surgical revisions are frequently necessary. In our patients, the level of satisfaction
was assessed at least 6 months post-procedure. is period
is important since the breast shape continues to change, and
edema is a potential cause of volume distortion. At the time
of this writing, most patients were very satised or satised
with their results. Moderate to major fat necrosis and other
major complications were not observed. e nal result was
generally good, and a soft transition between the subcutaneous tissue and BCS edges was observed in the majority of
cases (Fig. 14.6).
Oncologic Safety
Despite its positive aspects, the AFG technique for BCS
reconstruction is controversial.
have emphasized that AFG could result in distortions
and microcalcications, thus increasing the number of
8,29-31
In fact, some authors
A
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B
C
E
D
F
G
• Fig. 14.2 Decantation-filtration through closed system (PureGraft™ 250, Cytori Therapeutics, San Diego,
CA, USA). (A) The AFG-filled syringe is attached to the PureGraft™, fat is transferred and repeated until the
total desired graft volume between 50–250 mL is achieved. (B) The washing solution (Lactated Ringer’s
Solution) is inserted by syringe. (C) The tissue-filled PureGraft™ 250 manually agitated for approximately
15 seconds ensuring that all corners of the device are accessed. (D,E) The Slider is used to guide tissue
toward the port, while simultaneously filtering any remaining excess fluid into the waste bag. (F,G) Purified
AFG is extracted from the PureGraft™ 250 by slowly pulling the syringe plunger until syringe is filled. (H)
After this step, the AFG is transferred into 3-cc syringes for injection through blunt cannulas.
H
CHAPTER 14 Lipolling and Oncoplasty
Volume of AFG injected (cc)
Pressure Increased (mm Hg)
Pressure Compliance Curve, different tissue recipient beds
Pressure Limit
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A
C
B
D
• Fig. 14.3 AFG procedure. (A) Previous incision is utilized and AFG is injected into the subcutaneous
tissue of the near the defect area. (B) A 3.0-cc syringe connected to 1.9–2.1-mm cannula was utilized,
which permits the controlled precision necessary to graft. (C) The technique for injecting AFG is based on
preoperative topographic markings, where small amounts of fat are grafted by means of multiple passes
along several planes, from deep to subcutaneous tissue. (D) Final postoperative appearance after 100 cc
AFG injection on the lower pole of the left breast.
60
Decreased
Compliance
STIFF
TISSUES
30
0
0
Scheme 14.2 Pressure compliance curve with different tissue recipient beds. The pressure–volume (PV)
curve represents a physiological tool proposed for monitoring purposes during AFG and different recipient
areas aspects. Stiff tissues (previous surgery, RT local effects, severe fibrosis) presents reduced compliance and even small/moderate volumes of AFG can result in a higher tissular pressure (left curve). Contrary, pliable tissue (skin-sparing mastectomy, no fibrosis, no previous RT, previous external expansion)
presents a higher local compliance and large volumes of AFG can result in a minimal tissular pressure
augmentation (right curve).
100
Normal
Increased
Compliance
200 300
PLIABLE
TISSUES
(Survive)
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Scheme 14.3 Relation of volume, size of fat droplets, and fat intake due
to neovascularization. (A) With small fat droplets, an increased graftto-recipient interface is noted, resulting to fat intake due to the adipocytes adequately exposed to vascularization. (B) With a large volume
of AFG into the recipient bed, an increased interstitial pressure leading
to decreased tissue perfusion and less fat intake can be observed.
unnecessary biopsies and hindering breast cancer screen-
29-31
ing.
Because no clinical studies on safety have been performed, the Ad Hoc Committee on New Procedures from
the American Society of Plastic Surgeons (ASPS) reported
that any tissue scarring could interfere with early detection
of breast cancer and indicated that AFG could result in the
development of calcications, potentially aecting breast
cancer screening.39 In 2008, the ASPS established the Fat
Grafting Task Force, which stated that AFG may be considered for correcting breast defects associated with aesthetic
and oncologic situations.40 is committee concluded that
clinical studies did not suggest any interference with breast
cancer diagnosis and that AFG can be considered as a surgical option for breast surgery (both aesthetic and reconstructive) due to its low morbidity.
29-31,40
eoretically, it can be presumed that BCS would be
associated with a higher risk of local relapse following AFG
because much of the breast tissue is preserved. Fortunately,
recent clinical studies have pointed out that AFG does not
increase the risk of breast cancer recurrence.
8,29-31
However,
there are experimental and in-vitro studies that have suggested that AFG may induce tumor recurrence.
24,41
eoretically, the injection of adipose-derived stem cells (ADSC)
could activate silent tumor cells to reproduce and inuence local recurrence following BCS.42 In-vitro and in-vivo
experimental studies have demonstrated a positive and also
a negative association between breast cancer proliferation
and AFG.
43,44
However, clinical studies have not conrmed
an increased risk of local recurrence in patients undergoing AFG for BCS defects and have shown no increased
clinical risk of breast cancer in patients who undergo
9,10,13-15,24,33,42,45-51
AFG.
Delay et al published a large
report of 880 fat grafting procedures, including 42 cases
following breast conservation therapy (BCT), and observed
no increased rate of recurrence.45 Brenelli etal, in a series of
75 AFG procedures with a mean follow-up of 34 months,
observed a 4% rate of local recurrence following BCS,
which is comparable to previous studies which have shown
a rate of 1–1.5% per year.42 According to these authors,
patient selection and the lack of a control group to match
the results contributed to bias; most of the patients had a
good prognosis, with initial cancer stages (0, I, and IIA),
indicating selection for a low risk of recurrence following
BCS (Table 14.2).
Despite the oncologic safety demonstrated in these series,
there is controversy concerning AFG in patients with previous
ductal carcinoma in situ, particularly those patients receiving BCS.47 However, more recent studies demonstrated no
signicant dierences in the risk of local recurrence between
breasts reconstructed with and without AFG in either the
invasive breast cancer or in situ cancer subgroups.
48,49
Furthermore, other studies did not nd signicant dierences
in the risk of local relapse between breasts treated with BCS
and breasts treated with total mastectomy along with AFG.48
More recently, some meta-analyses have drawn the same
conclusions in terms of safety and local recurrence between
groups of patients with and without AFG reconstruction.
52–54
Despite the safety outcome observed in our sample,
the long-term results of AFG for BCS have still not been
reported and determined in a large series. e existing data
in this specic eld are restricted to case series and retrospective reviews.
9,10,13-15,24,33,42,45-51
Nevertheless, it is our
impression that the rate of local recurrence after BCS and
AFG is probably similar to BCS without AFG. However,
we strongly recommend that before BCS reconstruction
with AFG, the patient be clearly informed about the risk
of local recurrence to consider the benets of AFG in
treating BCS defects.10 Also essential are imaging screening before AFG reconstruction and continuing imaging
surveillance based on the recommendations of the breast
surgery team.
Complications and Side Effects
In our study, most complications occurred in the late postoperative period; all were minor, predictable, and did not
aect the nal aesthetic outcome. Regardless of the aesthetic
benets, AFG associated with BCS reconstruction can present local complications. Previous training and surgical skills
are crucial to obtain a satisfactory result. Financial limitations are reported, and longer operative time is also mentioned as a relative disadvantage. Although this latter aspect
is partially true, it seems logical that additional operative
time is not so signicant once experience is acquired.
Short-term local complications are rare. Edema, ecchymosis, and small hematomas can be observed at the donor
area and in the reconstructed breast. ese complications
tend to resolve in 1–2 weeks depending on the patient
and the donor site, and the nal outcome can be noted
1–2 months after surgery. On the treated breast, especially
where RT eects are present, ecchymosis disappears in
CHAPTER 14 Lipolling and Oncoplasty
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A
C
B
D
• Fig. 14.4 Serial percutaneous fasciotomies technique through 18 gauge needle. (A) Left breast BCS
reconstruction, preoperative view of retraction and local fibrosis on the inferior and lateral quadrants. (B)
Ligamentous band release/percutaneous fasciotomies are performed through an 18 needle, intraoperative view. (C–E) Constriction bands are progressively released in multiple planes through slight transverse
movements at each puncture point, thereby creating a matrix that will better receive AFG. (F) Immediate
postoperative view following inferior medial percutaneous fasciotomies technique.
AB
CD
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• Fig. 14.5 Serial percutaneous fasciotomies technique through small lance. Left breast BCS reconstruc-
tion, preoperative view of retraction and local fibrosis on the lateral quadrants (A). Percutaneous fasciotomies is performed through a small lance, intraoperative view (B). Constriction bands are progressively
released in multiple planes through slight transverse movements at each puncture point, thereby creating a
matrix that will better receipt AFG (C–E). Immediate postoperative view following inferior medial percutaneous fasciotomies technique (F).
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