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C o n t rov e r s i e s i n Tot a l
B re a s t Re c o n s t r u c t i o n W i t h
Lipomodeling
Emmanuel Delay, MD, PhDa,b,*,
Andreea Carmen Meruta, MDa, Samia Guerid, MDa,c
KEYWORDS
Breast reconstruction Fat grafting Lipomodeling Fat transfer Lipofilling
KEY POINTS
In case of total breast reconstruction with fat grafts, patients should be carefully selected depend-
ing on their fat deposits, on the shape and size of the contralateral breast, and patient acceptance
of multiple surgeries.
When delayed breast reconstruction is performed, the breast envelope can be reconstructed using
a combination with an abdominal advancement flap.
With each lipomodeling session, more fat grafts can be transferred.
This surgery is a surgery with very satisfying results if the case selection is good and the surgeon is
experienced with fat grafting.
Fig. 1. Surgical technique for delayed breast reconstruction with lipomodeling. (A) Skin markings of the breast
base and abdominal advancement flap. (B) Abdominal advancement flap. (C) Separate sutures for inframammary
fold creation using the abdominal advancement flap. (D) Fat transfer into the pectoralis major muscle. (E) Pector-
alis major muscle saturated with fat grafts. (F) Final aspect at the end of surgery.
linked to 10-mL syringes filled with purified fat to keep in mind that the reconstructed breast is
grafts. The fat grafts are transferred from the not going to have very good central projection,
deep to the superficial planes into a crisscross so the balancing should diminish the projection
pattern. When the tissues are saturated (see of the contralateral breast.
Fig. 1E), the fat transfer is stopped, and the skin If needed, other fat transfer sessions can be per-
is closed in a classical manner over a drain (see formed every 3 months, until a satisfactory result is
Fig. 1F). obtained.
The next surgical step can be performed At the end of each surgery, the authors cover the
3 months later. The reconstructed breast can be breast with a Vaseline-impregnated dressing and
improved with a new lipomodeling session, lateral then a noncompressive dressing.
liposuction, and if the inframammary fold is not
satisfying enough, inframammary fold liposuction. POSTOPERATIVE CARE
Also, balancing surgery can be considered, such
as breast reduction or mastopexy. It is important, In the case of immediate breast reconstruction us-
when performing breast reduction or mastopexy, ing lipomodeling, the hospital stay is not affected
4 Delay et al
RESULTS DISCUSSION
Advantages
The authors first started performing complete
breast reconstruction with fat grafting in 2001. Total breast reconstruction with fat grafting is an
Although at first the idea was very appealing, the autologous, safe, and satisfying technique giving
authors soon discovered that the indications for good results without additional scars and a low
this technique are limited. The ideal patient has complication rate.
small breasts (A or B cup), and enough fat deposits The technique is simple and reproducible once
to perform 4 or 5 sessions of lipomodeling. In the the learning curve has been completed. The oper-
authors’ experience, there are fewer than 5% of pa- ation time is short, and usually the patient leaves
tients that demand breast reconstruction who the hospital in the evening. The postoperative
could qualify for this technique, and even fewer care is simple with no difficult dressings and quick
who are willing to have that many surgeries, mainly recovery. The final result is a breast with natural
because lipomodeling used in combination with consistency and evolution with time.
other autologous breast reconstructions gives bet- There is also the secondary advantage of lipo-
ter results. suction in several areas of the body, which
Fig. 2. Delayed left breast reconstruction by lipomodeling in a 50-year-old patient who had radiotherapy. Recon-
struction performed in 3 sessions (154 mL, 170 mL, 150 mL). Result 1 year after the last stage of lipomodeling. (A)
Preoperative frontal view. (B) Preoperative frontal view before the second lipomodeling session. (C) Preoperative
oblique lateral view before the second lipomodeling session. (D) Final result at 1 year follow-up frontal view. (E)
Final result at 1 year follow-up lateral view. (F) Final result at 1 year follow-up medial view.
Total Breast Reconstruction With Lipomodeling 5
Fig. 3. Secondary breast reconstruction by lipomodeling after latissimus dorsi flap failure in another hospital. The
result was obtained after 5 sessions of fat transfer: 136 mL, 225 mL, 205 mL, 340 mL, and 170 mL. Final result
1 year after the last stage of lipomodeling. (A) Preoperative frontal view. (B) Preoperative oblique lateral
view. (C) Preoperative frontal view before the second fat grafting session. (D) Donor area markings. (E) Final
result at 1 year follow-up frontal view. (F) Final result at 1 year follow-up lateral view. (G) Final result at
1 year follow-up medial view.
improves the global body appearance of the pa- If the patient has a small breast but not enough
tient, leading to an increased satisfaction rate. fat tissue donor sites, the technique cannot be
performed.
The result is experience dependent. In the
Disadvantages
beginning, the frequency of fat necrosis is higher
The main disadvantage for this type of breast but decreases toward the end of the learning
reconstruction is that a good result can be obtained curve. The surgeon must take into account that
after several surgeries, sometimes 5 or more, about 30% of the injected fat is going to be lost
which is a long process because between each in the 3 or 4 months after surgery.13 At first, only
operation there should be an interval of 3 months. small quantities of fat can be transferred because
Larger breasts than a B cup are very difficult to the recipient tissues are thin and fibrotic; then, the
reconstruct with a good projection of the recon- quantities will increase with every operation.
structed breast. The ideal breast size is A or B It is very important that the patient maintains a
cup, but most often, the patients with good fat re- stable weight, because weight variations can
serves have also big breasts. This is the reason the affect a good result, as the fat maintains the mem-
indication became marginal in the authors’ practice. ory of the donor site.
Fig. 4. Secondary case of a patient who had 2 sessions of lipomodeling in another service and who had reserves
for only one more fat grafting session. This patient is a case whereby the reconstructive decision was not well
considered. In this case, the right indication is autologous latissimus dorsi breast reconstruction and the final re-
sidual lipomodeling session. (A) Unsatisfying result after 2 lipomodeling sessions frontal view. (B) Unsatisfying
result after 2 lipomodeling sessions oblique lateral view.
6 Delay et al
multiple surgeries. In the authors’ experience, the 10. Lin JY, Wang C, Pu LL. Can we standardize the tech-
indications for this technique remain limited, but niques for fat grafting? Clin Plast Surg 2015;42(2):
for selected patients, the results can be satisfying 199–208.
and offer a new option in total autologous breast 11. Fournier PF. The breast fill. In: Liposculture the
reconstruction. syringe technique. Paris: Arnette Blackwell; 1991.
p. 357–67.
REFERENCES 12. Coleman SR. Facial recontouring with lipostructure.
Clin Plast Surg 1997;24:347–67.
1. Coleman SR. Long-term survival of fat transplants:
13. Delay E. Lipomodeling of the reconstructed breast.
controlled demonstrations. Aesthetic Plast Surg
In: Spear SE, editor. Surgery of the breast: principles
1995;19(5):421–5.
and art. 2nd edition. Philadelphia: Lippincott
2. Coleman SR. Structural fat grafts: the ideal filler?
Williams and Wilkins; 2006. p. 930–46.
Clin Plast Surg 2001;28(1):111–9.
14. Delay E, Delaporte T, Sinna R. Alternatives aux
3. Coleman SR, Saboeiro AP. Fat grafting to the breast
prothèses mammaires. Ann Chir Plast Esthet 2005;
revisited: safety and efficacy. Plast Reconstr Surg
50(5):652–72.
2007;119(3):775–85 [discussion: 786–7].
4. Losken A, Pinell XA, Sikoro J, et al. Autologous fat 15. Delaporte T, Delay E, Toussoun G, et al. Reconstruc-
grafting in secondary breast reconstruction. Ann tion mammaire par transfert graisseux exclusif : a
Plast Surg 2011;66(6):518–22. propos de 15 cas consecutifs. Ann Chir Plast Esthet
5. Delay E, Guerid S. The role of fat grafting in breast 2009;54(4):303–16.
reconstruction. Clin Plast Surg 2015;42(3):315–23. 16. Khouri R, Del Vecchio D. Breast reconstruction
6. Mojallal A, Foyatier JL. Historique de l’utilisation du and augmentation using pre-expansion and autolo-
tissu adipeux comme produit de comblement en gous fat transplantation. Clin Plast Surg 2009;
chirurgie plastique. Ann Chir Plast Esthet 2004; 36(2):269–80.
49(5):419–25 [in French]. 17. Ho Quoc C, Delay E. Tolerance of pre-expansion
7. Delay E, Garson S, Toussoun G, et al. Fat injection to BRAVA and fat grafting into the breast. Ann Chir
the breast: technique, results, and indications based Plast Esthet 2013;58(3):216–21.
on 880 procedures over 10 years. Aesthet Surg J 18. Kosowski TR, Rigotti G, Khouri RK. Tissue-engi-
2009;29:360–76. neered autologous breast regeneration with Brava-
8. Delay E, Gosset J, Toussoun G, et al. Séquelles thér- assisted fat grafting. Clin Plast Surg 2015;42(3):
apeutiques du sein après traitement conservateur 325–37.
du cancer du sein. Ann Chir Plast Esthet 2008;53: 19. Brown FE, Steven KS, Cohen SR, et al. Mammo-
135–52. graphic changes following reduction mammaplasty.
9. Sinna R, Delay E, Garson S, et al. La greffe de tissu Plast Reconstr Surg 1987;80:691–8.
adipeux : mythe ou réalité scientifique. Lecture 20. Hogge JP, Robinson RE, Magnant CM, et al. The
critique de la littérature. Ann Chir Plast Esthet mammographic spectrum of fat necrosis of the
2006;51(3):223–30. breast. Radiographics 1995;15:1347–56.