Commentary on: Donor Site Satisfaction Following Autologous Fat Transfer for Total Breast Reconstruction

See the Original Article here.

Following mastectomy, women are currently offered only 2 options for reconstruction of their breast: implants or flaps. A new third option, reconstruction by) alone, is rarely offered.¹ The authors of this study² are to be congratulated for thoroughly investigating this less-invasive and promising approach.

To properly evaluate this up-and-coming alternative, the Dutch Government Health Care Fund had the plastic surgeons at Maastricht University enroll mastectomy patients in a multicenter prospective randomized controlled study of breast reconstruction alternatives—the first such study to my knowledge. They compared reconstruction with expansion followed by implants vs reconstruction with AFT after external vacuum expansion. Their primary endpoint, the patient’s long-term satisfaction with her reconstructed breast as measured by the BREAST-Q questionnaire, is the reason we perform the procedure in the first place. In a preliminary report presented at the European Association of Plastic Surgeons (EURAPS) last year,³ these surgeons showed that external vacuum expansion and AFT was the alternative that resulted in the best BREAST-Q scores.

True to the mission of first doing no harm, the Dutch surgeons concurrently investigated the oncologic safety of AFT after cancer resection and found no downside.^4,5 In this report,² they investigate the effects of repeated large-volume fat harvesting on women who do not necessarily need liposuction. To determine whether patient satisfaction with their body is affected by this procedure, they used the BODY-Q questionnaire and compared their AFT-reconstructed patients with a matched control group of women who were reconstructed with implants but did not undergo liposuction. There was no difference: repeated fat harvesting did not significantly affect a woman’s satisfaction with her body. However, they unveiled some valuable issues that are worth elaborating.

Standard liposuction tools and techniques were developed to treat the lipodystrophy of patients with localized fat excess. Liposuction for the sake of breast reconstruction aims at gently harvesting fat from patients who do not necessarily have localized fat excesses while leaving no contour defects on the donor sites. To harvest from a thin layer of fat an even thinner layer, and to do it evenly over of a wide area, is a different type of liposuction that requires new tools and techniques. Here are a few of the lessons learned after sweating through a few thousand cases:⁶

1. In planning the harvest, use the palm measure technique.⁷ A male surgeon’s palm is about 10 cm × 20 cm or 200 cm² (150 cm² for female surgeons). Evenly harvesting only 0.25 cm from a palm measure already yields 50 mL of fat. The average woman’s thighs and flanks encompass multiple palm measures. Therefore, rarely ever turn down patients for being too thin. As a matter of fact, some of our most impressive results are in low-BMI patients.

2. Harvest with crisscrossing passes through multiple entry sites all around the donor area. We use at least 4 entry points per site per side. Liposuction can be geometrically compared to lines fanning out of an entry site. It therefore follows that the greater the number of entry sites, the more even the fanning distribution.

3. To harvest from multiple entry sites, use thin cannulas (≤3 mm) that penetrate through needle puncture wounds and leave behind minimal scars. Standard liposuction uses larger (>3 mm) cannulas that require 1 or 2 hidden incision entry sites and result in geometrically suboptimal evenness of harvesting.

4. Sprinkle the harvested fat, creating a fine mist-like layer with a long (at least 25-35 cm) cannula. Achieve evenness through randomness.

5. Excessively tumesce the donor site to increase its size. This makes it easier to harvest fat from the thinner patients. We typically inject at least 2 L of tumescent solution per side per donor area to be harvested, and often inject in total 6 or more liters of solution. We tumesce until the area is drum tight. Thickening the thinner donor will reduce the likelihood that repeated cannula passes along the same tunnel will leave a disruptive groove. To illustrate, if the donor is 1 cm thick, a 3-mm groove will leave a surface contour about one-third the panniculus thickness. But if tumescence increases that thickness 3-fold to 3 cm, the 3-mm groove will be much less noticeable, a 10% contour defect. And when the edema settles, will become a minuscule 0.3-mm groove. Excessive tumescence also has the advantage of reducing blood in the lipoaspirate, allowing it to sediment better and more rapidly.

6. Use power harvesting devices that loosen up the fibrous structural framework of the donor site and allow it to redrape evenly. Separation, Aspiration, and Fat Equalization (SAFE) liposuction offers an alternative, although is time-consuming and cumbersome compared to the truly vibrating cannulas.

7. Select the proper donor site. The abdomen and the anterior and lateral thighs are readily accessible, but as this study shows,² these are the problem areas. Contour defects there are most visible, and many women already have cellulite that will be worsened by any potentially uneven liposuction. Our favorite donor sites are the posterior flanks, the so-called love handles. There is plenty of fat to be harvested there even in the skinniest women. We return to this site often to reharvest. The skin there is thicker, liposuction improves waistline aesthetics, and digging around the mountain makes it look higher, leading to a “no touch” butt augmentation. However, on the downside, this site is best approached with the patient prone and mobilizing her during anesthesia is time and resource consuming.

8. A note of caution: Compared to the North European women in this study, and to many North American women, African and Asian women have thicker skin that is more forgiving of contour defects whereas their cannula entry site incision tends to leave uglier scars. Items 1 and 2 above therefore only apply to women of European descent.

We congratulate the authors for their thoroughness and encourage them to pursue their study of AFT breast reconstruction. Growing back in situ their lost breast with no incision, no foreign material, only needles, syringes and cannulas, might very well become the most attractive and the most common alternative for our mastectomy patients.

Disclosures

Dr Khouri owns stocks in Lipocosm, LLC (Key Biscayne, FL) and receives royalties from MTF Biologics (Edison, NJ) for the sales of Lipografter.

Funding

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

REFERENCES

Author notes