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S. Saha and M. Singhal
long parenchymal pedicles that may be damaged
and susceptible to fat necrosis because of radiation. Radiation therapy can cause chronic oedema
of the irradiated breast, as well as contraction and
scarring, causing initial post-operative symmetry
to be permanently altered.
21.1.7 Complications
The overall complication rates after reduction
ranges between 17% and 24%. The most common
complications are infection (2.8%), suture line
dehiscence (4.6%), skin necrosis, fat necrosis
(4.3%), partial or complete nipple areolar complex necrosis (0.9%), hematoma (0.9%), and
seroma (0.6%). Other complications can be
reduced nipple sensation, and asymmetries compounded by radiotherapy. Obese patients and regular smokers suffer from higher complication rates.
The complication rates of oncoplastic reduction
are similar to breast reduction for macromastia for
non-oncological reasons as well as oncoplastic
methods involving lesser tissue rearrangement.
If adjuvant chemotherapy is recommended, it
can begin after the incisions have healed and be
followed by radiation therapy. Complications
that hinder wound healing may cause chemotherapy or radiation therapy to be delayed.
21.1.8 Oncological andCosmetic
Outcome
In a meta-analysis comprising of 15 studies with
a minimum of 2years’ mean/median follow-up,
an overall loco-regional recurrence rate of 3.1%
and distant recurrence rate of 3.0% was reported
[3]. These outcomes are equivalent to those
obtained after a partial mastectomy with no
reconstruction. In the study by Fitoussi etal., a
positive-margin rate of 18.9% and a local recurrence rate of 6.8% was reported at 5 years of
follow-up [4]. In another study by Chakravorty
etal. [5] comparing 150 patients who underwent
oncoplastic reduction with 440 patients who
underwent BCT, the percentage of patients needing intervention for positive margins was 14.5%
for BCT compared to 6.6% with oncoplastic
reduction.
When the margins of a breast reduction are
positive, there is a debate on whether to reexcise or to do a complete mastectomy.
Oncoplastic reduction is thought to cause considerable tissue reorganisation, making sufcient
margin re-excision more difcult and a completion mastectomy is more likely.
In the meta-analysis by Piper et al. [3],
reported rates of re-excision and completion
mastectomy were 3.5 and 3.7%, respectively.
However, it is imperative to counsel the patients
about all possible complications, including the
possibility of completion mastectomy as the patterns of recurrence may be signicantly altered
because reduction surge leads to complete rearrangement of breast geometry potentially leaving
the margins obscure.
In the same meta-analysis comprising of
seven studies that reported the cosmetic outcome, more than 90% of patients reported satisfactory or improved outcomes. Breast
asymmetry, signicant scarring, and a lack of
nipple sensitivity were the most common reasons for patients reporting less-than-satisfactory
results.
21.2 Contralateral
Symmetrisation
With the rise in breast cancer survival rates and
an emphasis on cosmetic and patient-reported
outcomes, addressing the contralateral breast has
become an important element of breast cancer
treatment. As both the breasts contribute to the
aesthetic triangle, thus addressing the contralateral breast is essential to optimising the overall
cosmetic outcome. The advantages of symmetry
surgery on the non-disease breast, on the other
hand, may be more than just improved aesthetics. Occult cancers in the contralateral breast
have been discovered in several studies, with an
overall rate ranging from 0.16 to 5%.
Furthermore, there is evidence that breast reduction reduces the risk of breast cancer in women
over the age of 50.
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155
21.2.1 Factors Determining theNeed
andTiming ofContralateral
Symmetry Procedure
Various factors affect decision making, such as:
• Age.
• Comorbid status.
• Surgical factors such as type of mastectomy
(skin sparing / Non-skin sparing).
• Type of reconstruction (Autologous vs.
Prosthetic).
• Time of reconstruction (Immediate vs.
Delayed).
• Oncological risk factors.
• Need for adjuvant therapy.
• Pathologies in the contralateral breast.
Descision making
Algorithm
• Pre-surgery breast size and patients’ desired
breast size and shape.
• Post reconstruction patients’ expectations
regarding the size and shape.
• The nancial and social conditions and availability of insurance cover also determine the
patient’s decision.
• Surgeon factors such as expertise, preference
and availability.
21.2.2 Decision Making Algorithm
Patients with large breast undergoing large volume resection may be categorised into three
groups depending on their decision to undergo
symmetrisation and its timing:
Indication: Large breast with 20-50% volume
Patient unwilling for
contralateral procedures
Aim to keep diseased
breast as symmetric as
possible normal breast
WLE + appropriate
displacement/replacement
oncoplasty
(level II Oncoplastic Breast Surgery)
excision
Patient willing for
immediate
symmetrisation
procedure
Aim to leave the diseased
breast slightly larger to
precompensate the effect
of radiotherapy
WLE + bilateral breast
reduction (leaving diseased
breast slightly larger)
Patient willing for a delayed
symmetrisation procedure
Aim to provide optimal aesthetics to the
diseased breast after completion of
adjuvant therapy, contraleteral breast is reduced
using the operated breast as template
WLE + ipsilateral breast
reduction + delayed
contralateral symmetrisation
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S. Saha and M. Singhal
21.2.3 Rationale
Patient Satisfaction and Patient-Reported
Outcome Measures (PROMs) The overall
patient satisfaction is inuenced by the symmetry
of both the breasts. Most patients choose to have
the normal breast untouched. In patients with
symptomatic macromastia, ptosis, hypoplasia
and atrophy, surgery on the non-tumourous breast
may improve the overall cosmesis.
Restore Symmetry With advances in techniques for breast reconstruction and a paradigm
shift towards less extirpative procedures and
autologous reconstructions. The aim of restoring
the diseased breast similar to the volume of a normal breast may be difcult without a balancing
procedure on the unaffected breast.
Oncological Considerations A symmetrising
mammoplasty allows us to screen for breast cancer by examining the removed tissue for occult
cancers. Occult carcinoma is a rare malignancy.
It has been found that 1–5% of the removed
breast tissue contains occult cancer. The radiological surveillance for breast cancer is not
affected by the surgical procedure.
However, the use of implants for symmetrisation has been debated to confound the mammographic ndings of breast cancer. The presence of
capsular contracture and calcications may
obscure the ndings. Saline implants and submuscular placement of implants are easier to
image and minimise the obscuring effect of the
implant on the breast parenchyma.
Therefore, implant-based reconstructions require
balancing surgeries more often than autologous
reconstructions.
Immediate vs. delayed The benet of executing the symmetry treatment concurrently with the
reconstruction is that it eliminates the need for
another operation and general anaesthesia is
avoided. It has been proven that immediate
reconstruction results in reduced distress and
improved psychological outcomes compared to
those who have delayed reconstructions. It is axiomatic that similar outcomes would be expected
in delayed symmetrisation procedures.
The proponents of the delayed procedure tout
it as a more oncologically and cosmetically benecial procedure because of following reasons:
1. The foremost reason is change in the volume
of the operated breast following radiotherapy,
which may lead to size discrepancies if an
immediate symmetrisation has been
performed.
2. Prolonged operative time may increase the
anaesthetic risks and technical errors.
3. Procedures on the normal breast may double
the risk of complications and potentially delay
the commencement of adjuvant therapy.
4. Reoperations for positive margins or recur-
rences may further alter the breast volume.
5. Insurance reimbursements may not cover aes-
thetic surgery and may add to the cost of cancer surgery.
21.2.5 Conclusion
21.2.4 Technical Considerations
Implant vs. Autologous To match the opposite
breast, one may perform a reduction or an augmentation mammoplasty or a mastopexy. Implant
base reconstruction is more articial looking, and
with advancing age, the normal breast becomes
more ptotic compared to the breast with implant.
The advantages of symmetrising surgery on the
non-disease breast may be more than just
improved aesthetics. Occult cancers in the contralateral breast have been discovered in several
studies, with an overall rate ranging from 0.16 to
5%. A symmetrising mammoplasty allows us to
screen for breast cancer by examining the
removed tissue for occult cancers. Implant base
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157
reconstructions are more articial looking and
require symmetrising surgeries more frequently.
The timing of the procedure is a matter of debate,
however, depends on several patient and surgeon
related factors.
References
1. Clough KB, Kaufman GJ, Nos C, Buccimazza I,
Sarfati IM.Improving breast cancer surgery: a classication and quadrant per quadrant atlas for oncoplastic
surgery. Ann Surg Oncol. 2010 May;17(5):1375–91.
2. Dafydd H, Roehl KR, Phillips LG, Dancey A, Peart
F, Shokrollahi K. Redening gigantomastia. J Plast
Reconstr Aesthet Surg. 2011 Feb 1;64(2):160–3.
3. Piper ML, Esserman LJ, Sbitany H, Peled
AW.Outcomes following oncoplastic reduction mammoplasty: a systematic review. Ann Plast Surg. 2016
May;76:S222.
4. Fitoussi AD, Berry MG, Famà F, Falcou M-C, Curnier
A, Couturaud B, etal. Oncoplastic breast surgery for
cancer: analysis of 540 consecutive cases [outcomes
article]. Plast Reconstr Surg. 2010 Feb;125(2):454–62.
5. Chakravorty A, Shrestha AK, Sanmugalingam N,
Rapisarda F, Roche N, della Querci Rovere G,
et al. How safe is oncoplastic breast conservation?
Comparative analysis with standard breast conserving
surgery. Eur J Surg Oncol. 2012 May 1;38(5):395–8.
Lipomodelling inBreast Surgery
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DineshThekkinkattil
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22.1 Introduction
Lipomodelling or autologous fat grafting is the
removal of fat from one area of patient’s body
and re-insertion into the desired recipient site [1].
Several terminologies such as autologous fat
transfer, lipomodelling, lipolling, fat grafting,
and liposculpture are all in use to describe this
procedure. Fat has many properties that render it
as an ideal ller: it is autologous, soft, frequently
abundant, easily obtainable, repeatable, inexpensive, and biocompatible [2]. Autologous fat transfer was rst used in breast over a century ago [3].
Work by Delay and Coleman has been pivotal in
making this procedure gain popularity [4, 5]. It
has become a workhorse for oncoplastic breast
surgeons and is a great adjunct tool to improve
the aesthetic outcome after surgery.
22.2 Indications
Fat Grafting in Breast Conservation
Surgery Main indication for fat transfer is for
correction of contour deformity or volume decit
after breast cancer surgery [3] (Figs. 22.1 and
22.2).
D. Thekkinkattil (*)
Consultant Oncoplastic Breast Surgeon, Lincoln
County Hospital, Lincoln, UK
Fat Grafting in Implant Based Breast
Surgery It is a great tool to improve tissue cover
after implant reconstruction specially to address
the issue of rippling and camouaging the edges
of implant. With increasing popularity of prepectoral implant reconstruction, lipomodelling is
routinely used to create more natural anatomic
upper pole slope mitigating the step-off or rippling deformity [6–8]. In two staged expander
implant reconstruction, lipolling is often used at
the time of implant exchange to enhance skin ap
thickness and tissue cover over implant, cover the
edges of implants, and to address any rippling
deformity [7, 9]. Lately, hybrid reconstructive
techniques are used in breast reconstruction
based of tissue expansion followed by serial sessions of fat grafting to enhance the autologous
subcutaneous compartment along with a small
implant to obtain central core, projection and
additional volume [10]. In situations where
patients experience recurrent prosthetic associated infections, fat transfer has been used to
replace the volume after implant removal in suitable patients [11].
Fat Grafting in Autologous Breast
Reconstruction Delayed fat grafting can be
used to augment the volume of autologous ap
reconstruction without the use of any prosthetic
devices [7]. It is also used avoid any step deformity at the transition between tissue aps and the
native chest wall. Fat graft is also a useful tool in
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
S. V. S. Deo (ed.), Breast Oncoplasty and Reconstruction,
https://doi.org/10.1007/978-981-99-5536-7_22
159
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Fig. 22.1 Lipomoelling
to correct post-surgery
deformity. Preoperative
picture
D. Thekkinkattil
include postmastectomy pain syndrome, capsular
contracture pain, and irradiated tissue brosis
[15–18]. Radiotherapy induces broblast injury,
excessive scarring and reduced microcirculation
and pleuripotent cells in the grafted fat are postulated to improve angiogenesis through paracrine
signalling and endothelial recruitment [11].
Fig. 22.2 Lipomodelling to correct post-surgery deformity. Post-operative picture
volume augmentation in ap reconstruction of
breast and is particularly useful if explantation of
implant is needed due to complications [11, 12].
Fat Grafting for Whole Breast Reconstruction Recent studies have also shown that pri-
mary reconstruction using fat graft alone is
possible in the appropriate subset of patients
[13]. External expansion by application of vacuum via a specially designed bra (BRAVA
LCC,Miami,FL) is usually used to facilitate large
volume fat transfer in this setting [14].
Therapeutic Indications of Fat Grafting Pro-
posed therapeutic applications of lipomodelling
Fat Grafting in Aesthetic Breast Surgery Lipolling is extensively used tool in aes-
thetic and cosmetic breast surgery. Lipomodelling
is extensively used for correction of breast asymmetry, tuberous breasts, chest wall deformities
[19]. Breast augmentation can also be achieved
only by fat transfer in appropriate patients [20]. It
is also used to improve appearance after mastopexy and reduction procedures and to address the
effects of capsular contracture [21, 22].
22.2.1 Informed Consent
A detailed consultation and discussion about the
potential complications both at the donor site and
recipient sites should be carried out and documented. It is important to make patients aware of
the potential need for multiple serial sessions
under general anaesthetic to achieve the desired
outcome. Pre- and post-operative photographs
are helpful to monitor the progress as well as useful in decision making process.
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22.2.1.1 Preoperative Assessment
Patient should be t and prepared for multiple
procedures mostly under general anaesthesia.
Smoking increases fat resorption. Bleeding disorders and anticoagulant treatment increases risk
of bleeding and bruising. Patient should have
adequate donor site to harvest fat without incurring damage to underlying structures. Patient
should be counselled for impact of lipomodelling
on future breast imaging (it can cause changes
such as fat necrosis, oil cysts, calcications) and
may at times necessitate biopsy. Patient should
be counselled for donor site deformities such as
numbness, skin dimpling, fat necrosis, rarely
damage to underlying structures. Patients should
also be aware of variable degree of resorption
after lipomodelling. Most of the studies suggest
up to 30% resorption at 1 year after the
procedure.
22.2.2 Technique
Lipomodelling has three main stages.
1. Harvesting
2. Processing
3. Fat injection
Successful outcome depends on the technique
of harvesting, preparing, and harvesting the fat.
There is no agreement among clinicians as to the
ideal method for the harvesting and handling of
grafts.
22.2.3 Harvesting
Common donor sites used are anterior abdominal
wall, anks or saddlebags, thighs, or knees. There
is no clear relationship proven in literature for
adipocyte viability and donor sites [23].
Harvesting mainly done by syringe or vacuum
aspiration. Low negative pressure vacuum aspiration helps to harvest larger volume of fat. High
vacuum pressures of conventional liposuction
may cause structural disruption in up to 90% of
adipocytes. Coleman technique uses a 3 mm
blunt cannula attached to 10 ml of Luer–Lock
syringe. Slight negative pressure is applied by
manually withdrawing the plunger [24].
Harvesting can be by ‘Dry’ or ‘Wet’ method.
In wet harvesting donor site is usually inltrated
with a solution containing local anaesthetic and
adrenaline and causes hydrodissection and
enlarges the target fat layer facilitating aspiration
[21]. It is associated with less pain and bruising.
In dry method tumescent solution is not used
and can lead to more pain at donor site. Studies
have shown that local anaesthetic and adrenaline
used in wet technique does not alter adipocyte
viability or uptake [25].
22.2.4 Fat Processing
The most used methods to prepare fat grafts are
sedimentation, ltering, washing, and centrifugation. This is necessary as harvested fat contains
blood, collagen bres, blood, and debris in addition to adipocytes. These elements can cause
inammation at the graft site and can be detrimental to the grafted fat. Blood can accelerate
degradation of fat. Comparative studies investigating the effects of fat processing with centrifugation, washing and ltration have showed no
signicant difference in fat retention [1].
In Coleman technique fat is centrifuged at
3000 rpm for 3 min. After centrifugation three
layers are observed: rst layer of oil, second layer
of concentrated adipocytes and bottom layer of
blood, tissue uid. Middle layer is used to graft
[2]. Recently commercially available lipoaspiration systems are available to process the fat by
selectively washing lipoaspirate while draining
superuous tumescent uid, free lipids, and
debris (Figs.22.3, 22.4 and 22.5).
22.2.5 Fat Grafting
Major limiting step in successful fat grafting is
oxygen diffusion and factors which can impair
revascularisation of grafted fat. The grafted fat
must be distributed in three-dimensional fashion
to create microdroplets that do not coalesce [26].
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D. Thekkinkattil
Normally small stab skin incisions are made to
insert the cannula and fat is injected in small aliquots and in different layers in three-dimensional
lattice format. Fat is injected only during withdrawal of cannula and is fanned out to varying
depths in soft tissue to avoid excessive interstitial
pressure at the recipient site and overcrowding of
transplanted adipocytes [27] (Fig. 22.6).
Attempting to graft more is counterproductive
and should take care to avoid overlling, otherwise there will be risk of fat necrosis and oil cysts
[28]. Fat is mainly grafted using blunt cannula.
However, grafting fat into scarred tissues may
Fig. 22.3 Puregraft ltration system for fat grafting
Fig. 22.5 Lipolter
gravity decanting system
Fig. 22.4 Vacuum assisted system for fat grafting.
(Microaire Liposuction and Lipolter System)
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Fig. 22.6 Cannulae
used in fat grafting
163
necessitate release of the scar prior to grafting. A
large bore needle or sharp tipped V cannulae can
be used to break the scar tissue to facilitate lipomodelling [29] (Fig. 22.6). This technique is
called three- dimensional ligamentous band
release or ‘Rigottomy’ [29].
It is natural to have a proportion of fat grafted
gets lost by resorption and this occurs usually
within rst 4–6months after the procedure [30].
Delay described this loss as ‘twice 30% rule’30% of the fat is lost during the liposuction and
centrifugation and another 30% is lost in the rst
4months following resorption [30].
Insufcient vascularisation, inammatory
response to the grafted fat and cellular damage
due to mechanical stresses have been associated
with fat resorption. Overlling can lead to
increased tissue pressure, poor capillary perfusion, and poor retention. Patient related factors
such as smoking can also inuence retention of
fat graft. Patients may be dissatised if lipolling
leads to further contour irregularities due to over
or under correction of the defect [31].
Several studies have been conducted to nd
ways to improve the viability of adipocytes by
using growth media, nutrients as part of process-
ing procedure. Unfortunately, heterogeneity in
the methodology and use of combination of
agents make it difcult determine clinical applicability [32].
22.2.6 Complications
Mostly the procedure is safe, and incidence of
complications are less frequent and mostly are
minor.
Donor site complications are bruising, swelling, haematoma, paraesthesia, donor site pain,
infection, hypertrophic scars, contour irregularities, and damage to underlying structures due to
intraperitoneal or intramuscular penetration of
cannula.
Lipolling in breast can cause fat necrosis, oil
cysts, and calcication especially when large volume is injected into a single area or injected to
poorly vascularised areas [33]. It can lead to palpable masses of fat necrosis. Agha etal. suggested
that complication rate after fat transfer was 7.3%
and fat necrosis accounted for 62% of these complications [34]. Sometimes these changes can be
difcult to differentiate from local recurrence and
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D. Thekkinkattil
may warrant additional imaging or biopsy in
3–15% of patients. Post- lipomodelling
calcication can be seen in 0.7%–4.9%. Hence
patients should be counselled about the impact of
fat grafting on future breast imaging and the possible need for biopsies to assess alterations.
Injecting fat in the recipient site can also cause
damage to surrounding structures such as chest
wall, pleura, and implant. This can potentially
lead to pneumothorax or loss of implant.
Fat Grafting and Oncological Safety Main
oncological concerns raised against lipomodelling was based on its oncogenic potential and
interference with tumour surveillance [28].
There have been hypotheses suggested regarding safety of lipomodelling include the risk of
recurrence secondary to increased growth factors that promote re vascularisation and interaction of growth factors produced by adipocytes
and progenitor cells with cancerous cells in a
paracrine fashion [35, 36]. Numerous studies
have conrmed comparable local, regional, and
distant recurrence rates with and without fat
transfer [37–39]. Furthermore, advancement in
radiology permits better differentiation between
post lipomodelling changes and neoplastic calcications [40, 41]. Consensus is that the lipomoelling procedure is oncologically safe and
does not signicantly increase cancer recurrence [42].
22.2.7 Post-Operative Care
Patients are usually advised to wear supportive
garments for both donor site and breast in the
post-operative period and this helps to reduce the
discomfort and bruising. Routinely patients will
not need any post-operative antibiotic cover.
References
1. Kakagia D, Pallua N. Autologous fat grafting:
in search of the optimal technique. Surg Innov.
2014;21(3):327–36.
2. Coleman SR. Structural fat grafts: the ideal ller?
Clin Plast Surg. 2001;28(1):111–9.
3. Agarwal K, Mistry M. Autologous fat transfer for breast surgery. Br J Hosp Med (Lond).
2017;78(8):448–52.
4. Coleman SR. Structural fat grafting: more than a
permanent ller. Plast Reconstr Surg. 2006;118(3
Suppl):108S–20S.
5. Delay E, Garson S, Tousson G, Sinna R. Fat injection to the breast: technique, results, and indications
based on 880 procedures over 10 years. Aesthet Surg
J. 2009;29(5):360–76.
6. Sbitany H. Important considerations for performing Prepectoral breast reconstruction. Plast
Reconstr Surg. 2017;140(6S Prepectoral Breast
Reconstruction):7S–13S.
7. Katzel EB, Bucky LP.Fat grafting to the breast: clinical applications and outcomes for reconstructive surgery. Plast Reconstr Surg. 2017;140(5S Advances in
Breast Reconstruction):69S–76S.
8. Highton L, Johnson R, Kirwan C, Murphy
J. Prepectoral implant-based breast reconstruction.
Plast Reconstr Surg Glob Open. 2017;5(9):e1488.
9. Hammond DC, O’Connor EA, Scheer JR.Total envelope fat grafting: a novel approach in breast reconstruction. Plast Reconstr Surg. 2015;135(3):691–4.
10. Stillaert F, Lannau B, Van Landuyt K, Blondeel
PN. The Prepectoral, hybrid breast reconstruction:
the synergy of Lipolling and breast implants. Plast
Reconstr Surg Glob Open. 2020;8(7):e2966.
11. Khouri RK Jr, Khouri RK. Current clinical applications of fat grafting. Plast Reconstr Surg.
2017;140(3):466e–86e.
12. Thekkinkattil DK, Salhab M, McManus
PL.Feasibility of autologous fat transfer for replacement of implant volume in complicated implantassisted latissimus dorsi ap breast reconstruction.
Ann Plast Surg. 2015;74(4):397–402.
13. Stark RY, Mirzabeigi MN, Vonderhaar RJ, Bucky
LP.Utilizing large volume fat grafting in breast reconstruction after nipple sparing mastectomies. Gland
Surg. 2018;7(3):337–46.
14. Khouri RK, Rigotti G, Khouri RK Jr, Cardoso E,
Marchi A, Rotemberg SC, et al. Tissue-engineered
breast reconstruction with Brava-assisted fat grafting:
a 7-year, 488-patient, multicenter experience. Plast
Reconstr Surg. 2015;135(3):643–58.
15. Turner A, Abu-Ghname A, Davis MJ, Winocour SJ,
Hanson SE, Chu CK. Fat grafting in breast reconstruction. Semin Plast Surg. 2020;34(1):17–23.
16. Caviggioli F, Maione L, Forcellini D, Klinger
F, Klinger M. Autologous fat graft in postmastectomy pain syndrome. Plast Reconstr Surg.
2011;128(2):349–52.
17. Papadopoulos S, Vidovic G, Neid M, Abdallah
A. Using fat grafting to treat breast implant capsular contracture. Plast Reconstr Surg Glob Open.
2018;6(11):e1969.
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