Commentary on: Scarless Composite Breast Reconstruction Utilizing an Advancement Skin Flap, Loops, and Lipofilling

It was my pleasure to review the paper published by Marwan Abboud et al.¹ Dr Abboud has pioneered the use of a combination of power-assisted liposuction and lipofilling (PALLL) for different indications. This time, the author applied tissue recruitment to this concept. The purpose of shortening the breast reconstruction process has been the ultimate goal for many surgeons. Indeed, tissue recruitment from the abdomen to avoid skin expansion was introduced by Emmanuel Delay in France. Delay combined an advancement abdominal flap with a latissimus dorsi pedicle flap to achieve a 1-stage procedure for delayed breast reconstruction.^2,3

When fat grafting is introduced to the breast, the major challenge is shortening of the skin. Surgeons need multiple sessions to achieve the required volume/contour of the reconstructed breast. Roger Khouri is considered the father of skin expansion/recruitment in fat grafting because of his introduction of the BRAVA technology and then the PLAF/RAFTS concept.⁴ More recently, Abboud took the concept to a different level through a very strong tissue mobilization thanks to his power-assisted liposuction (PAL) system.^5,6 The tissue became easier to mobilize when multiple tunnelizations were performed.

The second major issue was to keep the tissue on the new level and maintain the breast projection. The concept of a breast thread is not new. In fact, the method was invented in 1996 by Georgian plastic surgeon Marlen Sulamanidze.⁷ Utilizing loops for breasts was then readopted by Khouri⁴ and myself⁸ for several indications. Recently, Abboud et al¹ modified the technique for breast reconstruction to create the breast mound and shorten fat grafting from a multiple-session procedure to strictly the minimum.

In the current paper, the technique was indicated for either unilateral or bilateral breast reconstruction but specifically for small to moderate-size breasts. Obviously, patients should have sufficient fat deposits and tissue laxity. Breast skin that has been severely damaged either by radiotherapy or previous surgeries is contraindicated by the PALLL technique described in the paper (which involves the additional use of fixation loops). Microsurgical techniques of breast reconstruction are not among Dr Abboud’s armamentarium; therefore, it is difficult to situate the technique’s indications among the available options for breast reconstruction.

The abdominal/thoracic advanced skin plays a major role in the outcome. The authors utilized AutoCAD (Autodesk, San Rafael, CA) to measure the surface of the advanced skin; however, this is still a rough estimate, and the outcome is based on the resulting maintained skin recruitment, knowing that skin will relax to a certain extent due to simple skin laxity or loop loosening. With his growing experience, Dr Abboud has utilized different types of threads, the last of which was nonabsorbable. The passage of loops requires great experience because the margin for error is limited. Only objective studies with validated measurements can show the superiority of one thread over the others. Nonabsorbable threads may result in skin tethering/dimples with an undesirable level of fixation. Beginner surgeons should avoid utilizing nonabsorbable threads until they can master the whole concept.

The outcome of PALLL was excellent, with 97% of the patients requiring only 2 or 3 sessions of fat grafting. I strongly believe that when 4 or more sessions of fat grafting are needed to reconstruct the breast, it is better to consider other techniques based on flap surgery. Breast reconstruction completed in 6 to 8 sessions, as sometimes presented at scientific meetings, is conceptually wrong and is based more on surgeon ego rather than patient’s services.

The authors, like some other surgeons, describe their technique as “scarless,” but this is a misnomer. The whole technique is based on creating scar tissue, which will hold the breast in place. Many surgeons utilize terms such as “scarless,” “without scar,” “operating without knives,” and so on, which are just words for marketing propaganda. The term “mini-invasive” would be more suitable for such a technique.

Nevertheless, Abboud et al have presented a brilliant level of surgery with successful outcomes. The major advance of their technique is to reconstruct a sensate breast, which is the last step in any attempt to restore a woman’s breast. Finally, I would like to congratulate the authors for their valuable contribution to simplifying fat grafting breast reconstruction by reducing the number of sessions and making the process more efficient.

Disclosures

The author declared no potential conflicts of interest with respect to the research, authorship, and publication of this article.

Funding

The author received no financial support for the research, authorship, and publication of this article.

REFERENCES