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Indications and

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
Emmanuel Delay, MD, PhDa,b,*,
Andreea Carmen Meruta, MDa, Samia Guerid, MDa,c

 Breast reconstruction  Fat grafting  Lipomodeling  Fat transfer  Lipofilling

 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.

INTRODUCTION The technique of fat grafting is frequently used in

facial aesthetic surgery,12 as a complement in
Breast reconstruction has s first purpose of vol- breast reconstruction,13 and in general, for defects
ume and skin replacement. Many techniques across the body either produced by surgery or
were developed in order to obtain a better other types of local treatments, or because of
aesthetic result with little scar and functional congenital malformation.
impact, from implants to pedicled and free flaps. The ideal reconstructive technique should be
Fat grafting proved its efficacy,1–3 and it became easy to perform, with low impact on the patient’s
a constant tool in breast surgery. Fat transfer has body integrity, and should be reproducible, autol-
an important role when used as a complement ogous, and with minimal scars. In this context,
for breast reconstruction with different flaps,4–7 breast reconstruction with fat grafts, which are
or for the treatment of breast-conservative surgery also called lipomodeling,13,14 appears ideal. This
sequelae.8 technique can be used alone15 or in combination
There is still no consensus for fat harvesting, pu- with the BRAVA system.16–18
rification, and transfer methods.9,10 However, it The goal of this article is to present the
appears that most plastic surgeons adhere to surgical technique, indications, limitations, and
Coleman’s principles,1 which follow the work of controversies of total breast reconstruction with
Fournier.11 The authors have adapted these princi- lipomodeling.

ples for mega-volume transfer.

Disclosure: The authors have nothing to disclose.

Department of Plastic and Reconstructive Surgery, Centre Leon Berard, 28 Rue Laennec, Lyon Cedex 08
69373, France; b Private Practice, 50 Rue de la Republique, Lyon 69002, France; c Department of Plastic Surgery
and Hand, CHUV, Rue de Burgnon 21, Lausanne 1011, Switzerland
* Corresponding author. Centre Leon Berard, 28 Rue Laennec, Lyon Cedex 08 69373, France.
E-mail address: emmanuel.delay@lyon.unicancer.fr

Clin Plastic Surg - (2017) -–-

0094-1298/17/Ó 2017 Elsevier Inc. All rights reserved.
2 Delay et al

PATIENT INFORMATION the breast base is designed using the contralateral

breast as a pattern, and the abdominal advance-
The first consultation should give insight into the ment flap is marked to obtain 5 to 7 cm more
patient’s medical history and her expectations skin (Fig. 1A). In both cases, the donor sites are
from breast reconstruction. Each patient is marked.
informed in detail about the surgical technique, The authors begin to harvest the fat. During fat
its advantages and disadvantages, and the harvest, the operating nurse has time to prepare
possible complications. The patient needs to the fat grafts while surgery is continued. The fat
have a stable weight because the transferred fat grafts are harvested using a blunt 3.5-mm-diameter
keeps the memory of the original site. Between op- cannula linked to 10-mL Luerlock syringes after
erations, there is a 3-month pause to allow fat infiltration 1:1 with saline and epinephrine solution
integration. (1 mg epinephrine in 500 mL saline). The incisions
The authors clearly explain to the patient that to are performed with a number 15 scalpel, and their
obtain a good result several operations are position depends on the site to be harvested. The
required, between 3 to 5 for the nonirradiated surgeon creates a small and progressive negative
breasts and 1 to 2 more when irradiated. They pressure (2–3 mL) in the syringe using the hand in
explain that during the first sessions they are going order to reduce the trauma exerted to the adipose
to transfer small quantities of fat grafts and that the tissue. At the end of the operation, a Naropeine
purpose of these sessions is to improve skin tro- (Ropivacaine) 75 mg 50% solution is infiltrated in or-
phicity and thickness, not to bring significant vol- der to decrease the postoperative pain in the first
ume. The authors also tell patients that part of 24 hours after surgery. The incisions are closed by
the transferred fat will be lost in the postoperative points of rapid absorbable sutures.
period (over the first 3 months). The quantity lost is The harvested fat is treated by centrifugation at
estimated at about 30% of injected grafts. Patients 3000 rotations per minute for 20 seconds.
should expect ecchymosis and pain in the donor In the case of immediate breast reconstruction,
sites that diminish progressively over 2 to 3 weeks. the fat is transferred directly into the pectoralis ma-
In cases of delayed breast reconstruction, the jor muscle; the inframammary fold is fixed with
authors incorporate an abdominal advancement Vicryl 1 separate sutures, and the mastectomy
flap. The patient is informed about the possibility incision is closed in the classical manner. A drain
of a moderate asymmetry of the abdominal wall is used to drain the cavity. Three months later,
and that for the first week after surgery they the second surgery can be performed.
should keep a slightly bent position to avoid su- In the case of delayed breast surgery, depend-
tures tearing and loss of inframammary fold ing on the skin quality, the abdominal advance-
definition. ment flap can be performed during the first
A balancing surgery can be planned for the surgery or during the second or third when the
contralateral breast, depending on size and shape. skin has improved. The purpose of the abdominal
According to the authors’ protocol, patients with advancement flap is to bring in more skin and to
delayed breast reconstruction have a mastectomy create a new inframammary fold. The incision is
site ultrasound to rule out recurrence. The authors made through the mastectomy incision. The mas-
explain that this surveillance should be resumed tectomy scar is excised and sent for histopatholo-
1 year after finalizing reconstruction. gy examination. The skin on the upper pole is not
The recurrence risk is discussed with the patient undermined. The abdominal flap is dissected in a
along with the risk of a coincidence between lipo- tunnel fashion to the supraumbilical area (see
modeling and local relapse. Fig. 1B). Then, with the patient in a sitting position
on the operating table, the abdominal tissues are
SURGICAL TECHNIQUE pulled. The thumb is used to fix the future infra-
mammary fold. Then, the electric cautery is used
Total breast reconstruction with lipomodeling is to incise the superficial fascia. The lower rim is
suitable for women with small breasts, A and B fixed to the thoracic wall using Vicryl 1 separate
cup, that have enough fat deposits to allow 4 or sutures (see Fig. 1C), and this is used to hold the
5 harvesting sessions. tension. The upper rim is fixed to the thoracic
Before starting the surgery, an informed consent wall using a Vicryl 1 continuous suture, and this
is obtained. is used to define the inframammary fold. Once
Before surgery, the patient is marked in a stand- the abdominal advancement flap is in place, the
ing position. In cases of immediate breast recon- fat grafts can be transferred into the pectoralis ma-
struction, the breast base and the inframammary jor muscle and intro the advancement flap (see
fold are drawn. For delayed breast reconstruction, Fig. 1D) using a 2-mm blunt single-hole cannula
Total Breast Reconstruction With Lipomodeling 3

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

by the reconstruction time. If an abdominal The breasts reconstructed by fat grafting

advancement flap is performed, the patient is hos- are round, with little or no ptosis and a small
pitalized 1 or 2 days. The same hospital stay is or medium volume, as can be seen in Figs. 2
taken into account when a balancing surgery is and 3.
performed. For fat transfer surgery alone, the au- The problem with this technique is when the
thors perform an outpatient surgery. Mild analge- indication is forced and there are not enough
sics are prescribed. The dressing is changed donor sites, as it is observed in slim patients with
every 72 hours. Often the donor sites are marked medium breasts (Fig. 4). Today more and more
by ecchymosis, and usually they are the most secondary patients are being seen with bad results
painful after surgery; they disappear 2 to 3 weeks (see Fig. 4) and with no more fat usable for fat
after surgery. The breast has also mild ecchymosis transfer. It is therefore important to consider the
and edema. The final result after each surgery can right indication of this technique before starting
be evaluated after 3 months. to use this technique in a patient.

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
The result is experience dependent. In the
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

Usually, balancing to the contralateral breast is enthusiastic,17 an enthusiasm supported by litera-

performed, because the breast obtained by lipo- ture16,18 that described the reduction of fat grafting
modeling is round with little ptosis. sessions required to obtain a good breast volume
compared with the technique that did not use
Complications preexpansion.
The complications associated with this surgery are Over time, the authors’ enthusiasm decreased,
linked more to the satisfaction of the final result. because in their hands, the number of fat grafting
There are many patients that start the process of sessions did not differ considerably from the clas-
reconstruction with fat grafts by inexperienced sical technique, and in addition to this, the device
surgeons and find themselves 2 or 3 operations is very uncomfortable for the patient to wear and
later with almost no volume and not enough donor there is no reimbursement by health insurance in
sites to continue the process (see Fig. 4). In these France and Switzerland.
cases, the authors propose a change of the breast
reconstruction technique to flap or implant. SUMMARY
The surgical complications are mostly linked to
the fat necrosis that can be identified as oil cysts Total breast reconstruction with fat grafting was
or diffuse fat necrosis manifested as an indurated, very appealing in the beginning, especially in pa-
painful breast. Fat necrosis can be prevented tients that desired an improvement to their body
by avoiding overfilling of tissues with fat grafts contour associated with their breast reconstruc-
while respecting the “spaghetti” principle in a tion. The great advantage of this technique is
crisscross pattern from the deep to the superficial that new scars are not produced and a flap or
layers.5,7,13,15 foreign bodies are not used.
Other complications like fat embolism and pneu- Over time, enthusiasm decreased, and the tech-
mothorax are extremely rare. More frequently, the nique appears suitable only for patients with small
authors encounter infections that manifest as red breasts and good fat reserves who accept multiple
painful breast with or without oil discharge from surgeries.
one or more fat injection points. Infections are The latissimus dorsi flap with short scar and free
treated with oral antibiotics. flaps is a very good technique for breast recon-
struction, and fat grafting has an important place
Radiologic Aspects as an adjunct technique to reconstruction, or to
improve the skin quality in patients severely
Preoperative examination requires a thoracic wall affected by radiotherapy. Lipomodeling also has
ultrasound, depending on the thickness of the an important place as adjunct to implant breast
subcutaneous tissues. Before balancing of the reconstruction.
contralateral breast, ultrasound and mammogram In selected cases, when associated with an
are performed. One year after reconstruction, the abdominal advancement flap or in the case of im-
follow-up of the reconstructed breast is performed mediate breast reconstruction, the obtained re-
with ultrasound and with ultrasound and mammo- sults are natural and symmetric. In addition, they
gram for the contralateral breast once a year. benefit body contouring. Finally, the critical point
When the breast is reconstructed with fat grafts, is to select the limited patients in whom this tech-
breast imaging is marked by the presence of nique provides the right indication.
microcalcifications and fat necrosis, even if the Total breast reconstruction with fat grafting is an
latter is not clinically manifest. interesting solution in selected cases because it
Calcifications are a normal occurrence after lip- gives a natural result without additional scars or
omodeling, and they can be found in 20% of pa- difficult surgery. It can be performed either for im-
tients 1 year after surgery. These calcifications mediate breast reconstruction or for delayed
are normal and frequently found in all types of breast reconstruction. In both cases, several sur-
breast surgery.19,20 geries are required in order to obtain a good vol-
When there is the slightest doubt, the diagnosis ume. When delayed breast reconstruction is
is made by needle or open biopsy and histologic performed, an abdominal advancement flap is
examination. added for creation of the inframammary fold. The
amount of fat grafts transferred to the recon-
The Pace of the BRAVA System in Complete
structed breast increase with each session. In pa-
Breast Reconstruction with Fat Grafting
tients with radiation history, 1 or 2 more sessions
In 2012, the authors started using the BRAVA are required compared with nonirradiated pa-
system for complete breast reconstruction tients. The ideal candidate is a patient with small
with fat grafting. In the beginning, they were breasts and good fat deposits who accepts
Total Breast Reconstruction With Lipomodeling 7

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reconstruction. syringe technique. Paris: Arnette Blackwell; 1991.
p. 357–67.
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