INTRODUCTION
Breast reconstruction procedures are currently considered an integral part of breast cancer treatment.1,2 Available options include implants,1,2 fat grafting,3 or flaps, such as LD, TRAM, or DIEP.4 BRAVA (Brava)-assisted fat grafting is a recently developed alternative.5 In this article, we present a concept of breast reconstruction with fat grafting combined with internal tissue expansion. This technique has not been well described yet.6,7
CASE REPORT AND SURGICAL TECHNIQUE
A 44-year-old woman was admitted for a reconstructive procedure 1 year after the total mastectomy for invasive carcinoma T1c, N0, M0 (IIB) of the right breast. Because there was no metastasis to the sentinel lymph node, the oncologic surgery was augmented by intraoperative radiotherapy. A complementary chemotherapy was also used. The patient recovered well; mild ptosis of the contralateral breast was present (Fig. 1). Initially, the patient was qualified for reconstruction using the BRAVA system applied for 12 hours per night over 2 months and 4 subsequent fat grafting procedures at 2 month intervals. The procedures were performed under local anesthesia by harvesting fat from the abdomen and hips. Fat tissue was collected using the Coleman technique,8 with a 3-mm multiport cannula featuring several sharp side holes of 1 mm in diameter (Tulip Medical Products, San Diego, Calif.) at −0.75 atm of suction pressure. After centrifugation, the fat tissue was injected subcutaneously in front of the pectoralis major muscle. Although a total of 280 ml fat was transplanted, the result was not satisfactory and the patient was tired of using the BRAVA system (Fig. 2).
;)
Fig. 1.: A 44-year-old woman after right mastectomy for invasive carcinoma.
Fig. 2.: The patient after 4 fat grafting procedures and a total of 280 ml fat transplant—the result was not satisfactory and the patient was tired of using the BRAVA system.
The decision was made to reconstruct the breast using a combined tissue expander—fat grafting technique.6,7 The study was approved by the ethics committee of our institution and the patient gave informed consent for documentation and publication of the reconstructive technique; principles outlined in the Declaration of Helsinki have been followed.
Initially, an anatomic 350-ml breast tissue expander with an integrated port (Mentor Worldwide LLC) was implanted through an inframammary fold incision under general anesthesia and placed under the pectoralis major muscle. After wound closure, the expander was filled with saline up to a volume of 150 and 70 ml of fat graft harvested the same way as previously8 was injected into the subcutaneous space of the right breast. Two weeks later, the expander was filled up to 380 ml through the integral port.
Next, at 2 month intervals, 5 fat grafting procedures (as previously described) combined with gradual emptying of the expander were performed under local anesthesia in an outpatient setting.8 During each course, 50 ml of fluid was removed and 70 ml of fat was injected into the subcutaneous tissue over the expander. The breast volume remained constant, but the consistency of the breast gradually changed. We did not observe any complications, and after each procedure, the patient was able to return to normal activity after 1–2 days. When the expander was emptied down to 130 ml, it was removed through an incision in the inframammary fold and 70 ml of fat were transplanted. In total, the patient had 11 fat grafting procedures performed during 15 months (Table 1).
Table 1.: The Pros and Cons of Breast Reconstruction Combined with Internal Tissue Expansion
A month later, the left breast was lifted by a vertical technique. After 3 months, a reconstruction of the right nipple was performed using a star flap. Six weeks later, micropigmentation (tattooing) of the nipple/areola complex was performed. Six months after the end of the treatment, Vectra imaging (Canfield Scientific) confirmed satisfactory shape on both breasts with similar linear and volume symmetry (Video 1). (See video, Supplemental Digital Content 1, which displays 6 months after the end of the treatment, Vectra imaging confirmed symmetrical and satisfactory shape on both breasts, https://links.lww.com/PRSGO/B37.) MRI studies done on the same time demonstrated that the structure and vascularization of the reconstructed breast were comparable to the contralateral side (Fig. 3).
Video Graphic 1.: See video, Supplemental Digital Content 1, which displays 6 months after the end of treatment, Vectra imaging confirmed symmetrical and satisfactory shape on both breasts. This video is available in the “Related Videos” section of the Full-Text article on
PRSGlobalOpen.com or available at
https://links.lww.com/PRSGO/B37.
Six months after the end of the treatment, MRI studies demonstrated that the structure and vascularization of the reconstructed breast (right site) were comparable to the contralateral side (left site).
One year after the end of the treatment, the final effect was stable and satisfactory for the patient (Fig. 4). The natural consistency was also restored (Video 2). (See video, Supplemental Digital Content 2, which displays 1 year after the end of the treatment the natural consistency of restored breast was obtained, https://links.lww.com/PRSGO/B38.)
Fig. 4.: One year after the treatment, the final result of right breast reconstruction and left mastopexy is stable.
Video Graphic 2.: See video, Supplemental Digital Content 2, which displays, 1 year after the end of the treatment, the natural consistency of restored breast was obtained. This video is available in the “Related Videos” section of the Full-Text article on
PRSGlobalOpen.com or available at
https://links.lww.com/PRSGO/B38.
DISCUSSION
Breast reconstruction is an integral part of breast cancer treatment1,2; however, all currently available techniques have some disadvantages.
Reconstruction with implants allows for a quick volume and shape restoration but at the expense of different consistencies.1,2,9,10
Fat grafting over the implant significantly improved this state.11,12 However, leaving the implant in the reconstructed area of the breast is always associated with the risk of a capsule formation around the implant.13,14
LD, TRAM, or DIEP flaps are methods of choice in some cases15; however, these extensive procedures require microsurgical skills and longer hospitalization.
Reconstruction with fat grafting in conjunction with the BRAVA system became popular in recent years; however, the use of the external expansion is burdensome and requires strong motivation.3,5 Although concerns exist regarding graft viability, especially in patients after radiotherapy,16,17 some reports demonstrated good fat viability in poorly vascularized areas.18
This type of clinical experience has been the inspiration to use fat grafting combined with internal expansion for breast reconstruction. Injecting fat directly after reducing the expander’s pressure on the recipient site is conducive to its integration, as was the case in the experimental study.18,19 In contrast to fat grafting augmented with the BRAVA system, this protocol is less demanding for the patient. Rapid restoration of breast volume after implantation of the expander and subsequent gradual change of the breast consistency and shape encourage return to professional and intimate life seem to motivate the patient to continue the treatment.
Although we demonstrated successful breast reconstruction using this method, due to lack of data from the literature, we cannot equivocally determine possible benefits and risks of this protocol.
After appropriate preparation, the method can be used by surgeons experienced in fat grafting under standard conditions. In combination with further studies on fat tissue physiology, this may be a promising direction in breast reconstruction.
CONCLUSIONS
This study demonstrated a successful breast reconstruction using fat grafting and expander implantation. This simple, inexpensive technique does not require microsurgical skills. It allows restoring natural breast consistency and volume with minimal scarring. Although this protocol may be an interesting alternative for many patients, subsequent studies are needed to verify all potential benefits and complications.
ETHICS
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
REFERENCES
1. Hammond DC, Schmitt WP, O’Connor EA. Treatment of breast animation deformity in implant-based reconstruction with pocket change to the subcutaneous position. Plast Reconstr Surg. 2015;135:15401544.
2. Sigalove S, Maxwell GP, Sigalove NM, et al. Prepectoral implant-based breast reconstruction: rationale, indications, and preliminary results. Plast Reconstr Surg. 2017;139:287294.
3. Khouri RK, Rogotti G, Cardoso E, et al. Megavolume autologous fat transfer: part 1. Theory and principles. Plast Reconstr Surg.2015;133:550557.
4. Knox AD, Ho AL, Leung L, et al. Comparison of outcomes following autologous breast reconstruction using the DIEP and pedicled TRAM flaps: a 12-year clinical retrospective study and literature review. Plast Reconstr Surg.2016;138:1628.
5. Khouri RK, Eisenmann-Klein M, Cardoso E, et al. Brava and autologous fat transfer is a safe and effective breast augmentation alternative: results of a 6-year, 81-patient, prospective multicenter study. Plast Reconstr Surg. 2012;129:11731187.
6. Stillaert FB, Sommeling C, D’Arpa S, et al. Intratissular expansion-mediated, serial fat grafting: a step-by-step working algorithm to achieve 3D biological harmony in autologous breast reconstruction. J Plast Reconstr Aesthet Surg. 2016;69:15791587.
7. Manconi A, De Lorenzi F, Chahuan B, et al. Total breast reconstruction with fat grafting after internal expansion and expander removal. Ann Plast Surg. 2017;78:392396.
8. Coleman SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 Suppl):108S120S.
9. Pusic AL, Klassen AF, Scott AM, et al. Development of a new patient-reported outcome measure for breast surgery: the BREAST-Q. Plast Reconstr Surg. 2009;124:345353.
10. Spear SL, Pelletiere CV. Immediate breast reconstruction in two stages using textured, integrated-valve tissue expanders and breast implants. Plast Reconstr Surg. 2004;113:20982103.
11. Sommeling CE, Van Landuyt K, Depypere H, et al. Composite breast reconstruction: implant-based breast reconstruction with adjunctive lipofilling. J Plast Reconstr Aesthet Surg. 2017;70:10511058. doi:10.1016/j.bjps.2017.05.019.
12. Kanchwala SK, Glatt BS, Conant EF, et al. Autologous fat grafting to the reconstructed breast: the management of acquired contour deformities. Plast Reconstr Surg. 2009;124:409418.
13. Muresan H, Lam G, Cooper BT, et al. Impact of evolving radiation therapy techniques on implant-based breast reconstruction. Plast Reconstr Surg. 2017;139:1232e1239e.
14. Unger JG, Carreras JM, Nagarkar P, et al. Allergan style 410 implants for breast reconstruction: a prospective study in efficacy, safety, and symmetry. Plast Reconstr Surg. 2016;138:548555.
15. Selber JC, Nelson J, Fosnot J, et al. A prospective study comparing the functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on the abdominal wall: part I. unilateral reconstruction. Plast Reconstr Surg. 2010;126:11421153.
16. Delay E, Garson S, Tousson G, et al. Fat injection to the breast: technique, results, and indications based on 880 procedures over 10 years. Aesthet Surg J. 2009;29:360376.
17. Hamza A, Lohsiriwat V, Rietjens M. Lipofilling in breast cancer surgery. Gland Surg. 2013;2:714.
18. Gassman AA, Lewis MS, Lee JC. Remote ischemic preconditioning recipient tissues improves the viability of murine fat transfer. Plast Reconstr Surg. 2016;138:55e63e.
19. Doi K, Ogata F, Eto H, et al. Differential contributions of graft-derived and host-derived cells in tissue regeneration/remodeling after fat grafting. Plast Reconstr Surg. 2015;135:16071617.
