Percutaneous Fasciotomies and Fat Grafting: Indications for Breast Surgery

Transcription

1 INTERNATIONAL CONTRIBUTION Breast Surgery Percutaneous Fasciotomies and Fat Grafting: Indications for Breast Surgery Christophe Ho Quoc, MD; Raphaël Sinna, MD, PhD; Azouz Gourari; Sophie La Marca, MD; Gilles Toussoun, MD; and Emmanuel Delay, MD, PhD Fat grafting is rapidly growing in popularity, and indications for fat grafts in breast surgery have now been validated for reconstruction 1 and congenital or acquired malformations in the context of appropriate clinical and radiological follow-up. Fat grafting improves tissue trophicity and aesthetics with natural and durable results. However, the techniques involved with this procedure require a learning curve, 2 and some cases are very difficult to improve because of breast shape retraction. Percutaneous fasciotomies, initially described for burn sequelae 3,4 and for the treatment of Dupuytren s disease (aponeurotomies), allow the release of fibrotic tissue and a higher volume of fat transfer. This technique can usefully contribute to Aesthetic Surgery Journal 33(7) The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journalspermissions.nav DOI: / X Abstract Background: The management of breast deformities can be very difficult in the presence of breast shape retraction. Percutaneous fasciotomies, which release fibrous strings, can be a very useful tool for shape improvement in the recipient site for a fat graft. Objectives: The authors evaluate the efficacy of fasciotomies in association with fat grafting in breast surgery. Methods: A retrospective chart review was conducted for 1000 patients treated with concurrent fasciotomies and fat grafting between January 2006 and December The recipient site was prepared with fasciotomies, and fat was harvested from other parts of the body using a low-pressure 10-mL syringe lipoaspiration system. Fat was centrifuged and injected into the breast for reconstruction or chest deformities. The postoperative appearance of the breast scars was scored by both the surgeon and the patient. Each complication was recorded, including instances of hematoma, infection, tissue wounds, scar healing, and fat necrosis. Results: In this series of patients, for whom the primary indications for the procedure were sequelae of breast-conserving surgery after cancer, latissimus dorsi flap breast reconstruction, breast implant reconstruction, tuberous breast, Poland syndrome, and funnel chest, we recorded the following complications: 0.8% local infections (8/1000), 0.1% delayed wound healing that required medical care (1/1000), and 3% fat necrosis (31/1000). Fasciotomy scarring was considered minor by the patient in 98.5% of cases and by the surgeon in 99% of cases at 1 year postoperatively. Conclusions: Fat grafting is a safe and reliable technique that improves the aesthetic outcomes of breast surgery. Percutaneous fasciotomies provide excellent aesthetic results and an improvement in breast shape with no scarring. In our experience, both fat grafting and fasciotomies offer a durable result over the long term. Level of Evidence: 4 Keywords fat grafting, percutaneous fasciotomies, breast reconstruction, tuberous breast, breast deformities, lipomodeling Accepted for publication August 13, From the Department of Plastic and Reconstructive Surgery, Centre Régional Léon Bérard, Lyon, France. Corresponding Author: Dr Christophe Ho Quoc, Department of Plastic and Reconstructive Surgery, Léon Bérard Center, 28 rue Laennec, Lyon, France. docteur.hoquoc@gmail.com Scan this code with your smartphone to see the operative video. Need help? Visit

2 996 Aesthetic Surgery Journal 33(7) Figure 1. (A, B) The fasciotomies are performed with a 14-gauge trocar. preparation of the fat graft recipient site, 3,4 but overly aggressive fasciotomies may also decrease the vascularization of the skin. Potential complications include wounds, infections, and fat necrosis. Therefore, fasciotomies must be performed with caution. The objective of this study was to evaluate the role of fasciotomies with concurrent fat grafting in breast surgery. Methods A retrospective chart review was conducted of 1000 consecutive patients who underwent fat grafting with percutaneous fasciotomies in the breast between January 2006 and December The presence or absence of previous radiotherapy was included. Surgical indications were breast reconstruction after cancer (total mastectomy with irradiation, total mastectomy without irradiation, sequelae of breast conservation after cancer treatment), secondary improvement of latissimus dorsi flap reconstruction or breast implant, and chest and breast malformations (tuberous breast, asymmetrical breasts, funnel chest, and Poland syndrome). Clear, honest, and appropriate information was given to each patient, and all patients gave their informed consent. Each surgical procedure was performed under general anesthesia. Fat grafts were harvested after infiltration with adrenaline and saline (1 mg of adrenaline in 500 ml of 0.9% saline serum) using a 10-mL Luer-Lok syringe with a multiperforated cannula. The harvested fat tissue was centrifuged at 3000 rpm for 3 minutes between 2006 and 2009 and for 20 seconds after Breast incisions were made using a 14-gauge trocar, and fat tissue was reinjected while withdrawing a disposable 2-mm monoperforated cannula. Fat grafting was performed from the deep zone toward the surface, starting in the plane of the ribs and then ascending into the pectoralis major muscle as far as the subcutaneous Figure 2. The result of fasciotomies, showing passive drainage of fatty secretions after fat grafting. plane. A large number of different tunnels were dissected to create a 3-dimensional grid. 2 Breast percutaneous fasciotomies in fibrous areas and areas with excessive tension were also performed to improve the shape of the breast. Manual meshing was performed with a 14-gauge trocar (Figure 1) into the breast skin that was under excessive tension. 3,4 We applied a double hook retractor to put the tissues under maximal tension and a 14-gauge trocar to release the fibrous strings in every layer (deep plane, glandular plane, and subcutaneous plane). (A video of this technique is available at You may also scan the code on the first page of this article with any smartphone to be taken directly to the video on These fasciotomies released fibrous adhesions. Passive drainage was ensured via the fasciotomy orifices; a fatty discharge was usually observed (Figure 2). A second phase

3 Ho Quoc et al 997 of fat injections during the same procedure was sometimes performed after release of fibrous adhesions by the fasciotomies, until the recipient sites were saturated with adipose tissue. When the breast site was saturated with adipose tissue, fat tissue exited through other injection holes. At that point, we did not perform any fat grafting, owing to the risk of fat necrosis. As a clinical example, the patient shown in the video underwent fat grafting to improve a left tuberous breast. After fat grafting, we performed fasciotomies in every layer (deep planes, glandular plane, and subcutaneous plane) to release excessive tension on the skin. We did graft an additional volume of fat in the same procedure. We also performed symmetrization of the right breast. Breast sutures were placed with very fine, rapidly absorbed suture material. A paraffin gauze dressing alone was applied to the whole breast, and a compressive dressing was applied to the area of liposuction. (The latter was removed 5 days after surgery.) Other clinical results are shown in Figures 3 and 4. For the entire patient series, the number of sessions, the fat graft donor site, and postoperative complications of the recipient site were recorded. The scar was evaluated by the patient and by the surgeon on a 4-point scale: minor, visible, very visible, or pathological. Results The average age of the 1000 patients included in this series was 39 years (range, years), and the average length of follow-up time was 4.5 years (range, 1-7 years). Surgical indications were sequelae of breast-conserving surgery after cancer treatment (Figure 3), second phase of latissimus dorsi flap or implant breast reconstruction (3 months after the first phase), tuberous breast (Figure 4), funnel chest, and Poland syndrome. The planned number of sessions ranged between 1 and 3 sessions per case. There were 3 months between each surgical procedure. Fasciotomies to release zones of tension were systematically performed on adhesions during each fat graft. The planned sequence of fat graft harvesting was abdominal (patient in the supine position) for the first phase, hips and trochanteric region (patient in the prone position) for the second phase, and both positions for the following phases. The incidence of complications included 8 local infections (0.8%) for breast conservation surgery after radiation, 1 case of delayed wound healing that required medical care (0.1%) for breast conservation surgery after radiation, and 31 cases of fat necrosis (3.1%). Fasciotomy scarring was considered minor by the patient in 98.5% of cases and by the surgeon in 99% of cases at 1 year postoperatively. The scar was considered visible in the other cases. In our clinical experience, we obtained about 70% retention of volume at 3 months after the fat grafting procedure. 1,2 Discussion Fasciotomies are usually performed in plastic surgery for the treatment of burn sequelae. 3,4 We decided to extend the indications for percutaneous fasciotomies in breast surgery with fat grafting. These procedures create a real manual meshing, equivalent to what is performed for fullthickness skin grafts. They facilitate drainage through the skin graft while avoiding detachment of the grafted skin. 3,4 We have also observed a fatty discharge from fasciotomies after fat grafting, which perhaps leaves better quality adipose tissue in place. The percutaneous fasciotomy technique is also used in hand surgery (aponeurotomies). Some authors 5-7 have described this technique for the treatment of Dupuytren s disease. The fibrous tissue present in Dupuytren s disease, responsible for major functional repercussions in the hand, is released by a simple percutaneous needle aponeurotomy. van Rijssen et al 5 conducted a 5-year randomized study to compare the efficacy of the usual limited aponeurotomy technique with that of the percutaneous aponeurotomy technique. A higher recurrence rate was observed with percutaneous aponeurotomies, but patients preferred this technique due to the minor scars and the atraumatic nature and simplicity of the procedure. In the event of recurrence of the adhesions, patients continued to prefer percutaneous aponeurotomies as surgical treatment. A review of the literature did not reveal any trophic complications secondary to percutaneous fasciotomies. Foucher et al 8 studied the possible complications of fasciotomies in the hand in a series of 211 patients. No unsightly scars, hematomas, or infections were observed. Cheng et al 9 did not report any skin wound or delayed healing complications. No local complications were observed in our series of 1000 cases, apart from 1 case of delayed healing. The combination of fasciotomies and fat grafting is an innovative concept in reconstructive surgery to improve the shape of the breast. To our knowledge, only 1 article has been published on this subject, in the field of hand surgery. Hovius et al 10 studied the effect of fat grafting and fasciotomies in 91 patients with Dupuytren s disease. This combination yielded excellent results in the fibrous tissue, and the authors reported only 1 case of local infection, which did not result in additional scar tissue. Fat grafting in breast surgery has had a very important place in our clinic since In our experience, fasciotomies are indicated when the recipient tissues are fibrotic with poor compliance. The best indications are sequelae of breast-conserving procedures after cancer treatment, breast reconstructions in patients with a history of radiotherapy, tuberous breast, funnel chest, and Poland syndrome. Sequelae of breast-conserving procedures are difficult to treat due to the associated adjuvant radiotherapy. Khouri et al 11 and Khouri and Del Vecchio 12 highlighted the role of fat grafting at the recipient site. Preexpansion of the recipient site enlarges the interstitial space, increases the blood supply, and determines both the number of fat grafting sessions required and the graft take. Del Vecchio 13 also considered that preparation of the recipient site is an important factor in the success of fat grafts. Rigotti et al 14 demonstrated the importance of the stromal vascular fraction (SVF) in preparation of the

4 998 Aesthetic Surgery Journal 33(7) Figure 3. (A, C, E) This 58-year-old woman presented with severe sequelae after breast-conserving treatment in her left breast. (B, D, F) One year after 2 fat grafting sessions (324 ml to the left breast for the first session; 270 ml to the left and 137 ml to the right breast for the second session). harvested fat tissue. Adipose tissue is richly endowed with stem cells with a preserved potential for multiple differentiation. The SVF induces the secretion of angiogenesis factors. Neoangiogenesis, especially on radiation-induced lesions, improves tissue oxygenation. Late trophic adverse effects related to radiotherapy do not improve spontaneously, 14 and fat grafting is a minimally invasive solution to improve the trophicity of irradiated tissues. It constitutes conservative

5 Ho Quoc et al 999 Figure 4. (A, C, E) This 16-year-old girl presented with left tuberous breast. (B, D, F) Two years after 2 fat grafting sessions (133 ml to the left breast for the first session; 240 ml to the left for the second session and a reduction mastopexy of 100 g for the right breast). surgery of damaged tissues comprising treatment with adipocyte stem cells. The current trend in reconstruction of sequelae of conservative treatment of breast cancer consists of the use of fat grafts The contribution of fat grafts to autologous flap breast reconstruction has now been clearly established. In our experience, the latissimus dorsi flap without implant constitutes the most adapted tissue to receive fat grafts because of its

6 1000 Aesthetic Surgery Journal 33(7) very rich blood supply. 1 This muscle is a suitable tissue to induce excellent quality revascularization of grafted adipocytes. 1 Analysis of our results on 200 latissimus dorsi flap breast reconstructions without implant 19,20 showed that a single fat graft with a mean volume of 176 ml was sufficient to achieve a satisfactory result in 78% of patients, while 22% of patients required 2 to 3 procedures. The result remained stable beyond the sixth postoperative month. We believe that percutaneous fasciotomies associated with fat grafts help to decrease the number of treatment sessions by ensuring better long-term graft take. 20 We can indeed graft a higher volume of centrifugated fat into fibrous areas after fasciotomies. Tuberous breast is a breast malformation that results from abnormality of the base of the breast. 21 Fat grafting appears to be a very useful complementary technique in the treatment of tuberous breast. 17,18 We have used fat grafts in this indication since 2000, and the long-term results are very satisfactory. We also perform fasciotomies to release the fibrous attachments observed in tuberous breast. The best indications are tuberous breast with a fibrous tissue in the lower pole of the breast and lack of fullness of the upper pole of the breast. 21 Fat grafting associated with fasciotomies in breast reconstruction or to improve congenital or acquired breast malformations provides a number of advantages 1 : breast shape improvement, larger volume of fat transfer during a single procedure, maintenance of the purely autologous nature of the surgery, 1,2 relatively low cost, reproducibility of the technique (which can be repeated in the case of an insufficient result), possibility to obtain a breast with a natural appearance and tissue consistency, 22,23 and symmetry to the contralateral breast, along with the secondary benefits of lipoaspiration on the patient s body shape. In our clinical experience, fat grafting in breast-conserving surgery does not increase local recurrence of cancer after a preoperative screening, including tumor histology and magnetic resonance imaging. Studies are in process in our department to evaluate this risk accurately. The limitations of percutaneous fasciotomies include the risk of pathological scar tissue: even if scars are very small, greater precautions are required in patients at risk of keloids 24 (adolescent girls with high hormone levels, as well as Asian or black patients) by limiting the number of fasciotomies. We also limit fasciotomies in cleavage areas, as potential residual scars would be difficult to hide. Finally, in our series, fasciotomies were not a supplementary risk factor for local infection or for fat necrosis after fat grafting. Conclusions Fat grafting in the breast represents major progress in plastic and reconstructive breast surgery and one of the greatest advances over the past 20 years. These procedures improve the trophic quality of the tissues and allow a tailor-made increase of volume. Percutaneous fasciotomies release fibrous tissues and improve the shape of the reconstructed breast. They improve breast lipomodeling results and do not leave any additional scarring when appropriate indications are respected. In our experience, the major indications for fasciotomies are reconstruction of the irradiated breast, sequelae of breast-conserving treatment for cancer, and tuberous breast. Acknowledgments The authors thank Andreea Meruta for translation assistance. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. References 1. Delay E, Ho Quoc C, Toussoun G, Garson S, Sinna R. Reconstruction mammaire autologue par lambeau musculo-cutanéo-graisseux de grand dorsal pédiculé. In: Techniques chirurgicales Chirurgie plastique reconstructrice et esthétique. Paris, France: EMC (Elsevier Masson SAS); 2010: C. 2. Delay E, Moutran M, Toussoun G, Ho Quoc C, Garson S, Sinna R. 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