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Immediate Reconstruction of Total Mastectomy Defects with Autologous Fat Transfer and External Expansion: A Four-Year, Forty-Two Patients Multicenter Experience.
Roger K. Khouri, MD1, Efimiano Cardoso, MD1, Alessandra Marchi, MD2, Gino Rigotti, MD2.
1Miami Breast Center, Key Biscayne, FL, USA, 2University of Verona, Verona, Italy.
PURPOSE: Immediate post-mastectomy breast reconstruction is considered ideal. The muscles exposed by the mastectomy are good recipients for large volumes of autologous fat. The fat filled muscle immediately re-creates a breast mound and acts as a larger recipient matrix for subsequent external expansion and additional lipografting. We hereby report our experience with this novel minimally invasive method of immediate post mastectomy reconstruction.
METHODS: We performed 42 immediate post-mastectomy fat graft reconstructions on 26 women, (16 bilateral, 7 irradiated). At the completion of the mastectomy, and under direct vision, we meticulously laid down in a diffuse, even 3D pattern, fat graft strips between the muscle fibers devoid of fascia. From the submuscular plane to the thoracic muscles, the lateral thoracic fascia, to the base of the skin flaps, we grafted 300-500 ml of fat while strictly avoiding collections larger than 2mm, maintaining graft to recipient interface, and avoiding increased interstitial pressure. One month later, once the flaps adhered to the muscle, the grafted area was externally expanded for one month and percutaneously grafted again with another 300 - 600 ml of fat suspension. External expansion was resumed post grafting for another two months in preparation for subsequent post mastectomy grafting till the reconstruction was deemed satisfactory by the surgeon and the patient.
RESULTS: Immediate reconstruction added 30 min/breast to the procedure as we harvested the fat during the mastectomy. Women woke up from the mastectomy with small breast mounds that subsequently grew with external expansion and serial lipografting. Of the 35 non-radiated breasts, 26(74%) were completely reconstructed with only two minor (1hr/breast) outpatient lipografting procedures completed within 6 months. An additional 1-2 more procedures were required in 3(9%) mastectomies complicated by post-operative seromas and in 6(17%) skin sparing mastectomies complicated by dense scar adhesions of the excess skin folds to the muscles. Depending upon size requirements irradiated defects required 3(5/7=71%) or 4(2/7=39%) post-mastectomy lipografting procedures. At 6 months follow up, all reconstructed breasts looked natural and pendulous, felt soft, and had light touch sensation over the reconstructed nipples. MRI revealed normal fat with occasional well recognizable small oil cysts. All patients felt as if they re-grew back their own breasts and considered the liposuctions an added cosmetic bonus.
CONCLUSION: Total breast reconstruction with lipografting can be ideally started at the time of the mastectomy. Mastectomy exposes muscles devoid of fascia and a unique opportunity to lay under direct vision very large graft volumes as strips of fat dispersed in between the muscle fibers. By avoiding localized collections and increased interstitial pressure, graft survival is ensured in this excellent 3D recipient scaffold. The resultant markedly swollen fat infiltrated muscle is an immediate post-mastectomy small breast mound. While skin preservation helps previous reconstruction methods, we found excess skin to be detrimental; our best results were obtained when the mastectomy skin flaps were loosely re-draped over the fat engorged muscles. Our experience shows that it is possible to regenerate in-situ a sensate and aesthetically appealing breast mound with only 2 minor post-mastectomy lipografting procedures.
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