LIPOMODELLING: AN IMPORTANT ADVANCE IN BREAST SURGERY

INTRODUCTION

Transferring fat from an area where it is present in excess to the breast in order to improve its shape and volume is not a new idea. Illouz, the author of liposuction (1), used fat from adipose deposits to increase the volume of the breast in 1983. Similarly, Bircoll described his technique of breast augmentation by fat injection in 1987 (2, 3, 4). Many surgeons were sceptical with regards to this technique, since the principles enabling fat transfer with little likelihood of focal fat necrosis were not established (5, 6). In addition, breast imaging was less advanced than it is today, and any swelling in the breast raised a potential diagnostic difficulty. The fact that injections of fat to a native breast could produce microcalcifications and result in development of cysts was the reason why the American Society of Plastic and Reconstructive Surgeons (ASPRS) was refused the use of autologous fat injection in breast augmentation in 1987. These statements were made without any references or scientific studies and were based on the opinion of the ASPRS committee members. Due to this prohibition, research and experimental studies in this field were stopped. Ironically, a retrospective study of mammographic changes after breast reduction that reported calcifications in 50% of cases at 2 years was published in the same journal at the same time (7, 8). In spite of that there was no discussion regarding the possibility to abandon breast reductions due to the risk of interference with breast cancer detection.

Interest in fat injection reawakened in the early nineties following the work of Coleman (9, 10), who confirmed that fatty tissue could be transferred satisfactorily if a strict protocol for fat preparation and injection was respected. Based on this work, we started our own research in 1998, aiming to evaluate fat transfer in the chest wall and breast. Our research enabled to develop this technique further and we called it lipomodelling (11). We were able to evaluate its efficacy and tolerance and to show that it is free of adverse clinical or radiological effects. We developed the technique of autologous breast reconstruction by latissimus dorsi flap and lipomodelling without the need of an implant (12, 13, 14, 15). The protocol was initially proposed for volunteer patients who agreed to undergo strict follow up. According to our findings that this technique was extremely effective and free of any adverse effects, we extended the indications. In the same time we performed mammography, ultrasound and MRI studies (16). Then we progressively extended the indications of lipomodelling to breast reconstruction in various contexts, to breast deformities, and then also to cosmetic breast surgery. Gino Rigotti, Italy, in 2002 started to use fat transfer in the breast, especially for the consequences of previous radiotherapy. His work is now well known worldwide, especially due to his article in the Plastic and Reconstructive Surgery 2007 in which he confirmed the effectiveness of fat transfer on the consequences of radiotherapy, and he emphasized the effectiveness of fat because of the contribution of stem cells (adipose tissue-derived stromal cells [ADSCs]) (17). Roger Khouri had the idea to combine the fat transfer with the use of the external vacuum expansion system Brava® that he invented in the late nineties (18). Many studies have now confirmed the efficacy of fat transfer to the breasts and for other various applications. An international scientific society called ISPRES (International Society of Plastic Regenerative Surgery), in which we are the founding member, has been established to explore the many possible applications of fat transfer. Its first meeting took place in Rome in March 2012. Fat transfer is currently accepted as a part of the armamentarium in breast reconstruction, for the consequences of conservative management, deformities of the breast and breast hypotrophy, and it is considered to be highly effective by the scientific community (19, 20).

The main aim of this paper is to present the advanced breast lipomodelling technique that we developed thanks to the long-term experiences and to review its success rate, complications, radiological and oncological aspects and indications.

SURGICAL TECHNIQUE

Patient preparation and anaesthesia

Patients obtain information about the operative technique and potential risks and complications and receive an information leaflet. It is important that the patient’s weight was stable at the time of the procedure, as the injected fat retains the memory from the area of its origin (if the patient loses weight after lipomodelling, she will lose some of the benefits of the procedure).

The various adipose areas of the body are examined to determine the distribution of the fat deposits. In general, abdominal fat is used first because harvesting from this area does not require any change in the patient’s position during the procedure and its removal is appreciated by the patients. The secondary sites include abdomen sides, trochanteric region and the inside of the thighs and knees. The harvesting areas as well as the areas of the breast that require correction are marked.

Prophylactic antibiotics are usually given preoperatively. No specific antibiotics are prescribed in case of lipomodelling. Lipomodelling is performed under general anaesthesia in the majority of patients. Local anaesthesia can only be used for minor revisions to correct any residual defect.

Fat harvest and fat preparation

Harvesting sites are infiltrated (500ml saline with 1mg of epinephrine). Incisions are made with a scalpel with No. 15 blade. For abdominal harvesting, 4 incisions are made around the navel and a lateral incision on each side if lateral abdominal and supra-iliac fat is to be harvested. For harvesting of fat from the thighs, an incision is made in each subgluteal fold, and often on the inside of the knees as well.

Special cannula with a blunt tip is used for the fat harvest (PLA 187, Pouret Medical, Clichy, France). Harvesting is done manually using a syringe. The 10 ml Luer Lock syringe is fitted directly on to the harvesting cannula. Suction is moderate (Fig. 1a) to minimize damage to the adipocytes. Excessive mechanical suction could have a harmful effect on adipocyte survival. Enough fat must be harvested to compensate for loss during centrifugation and for absorption after fat injection.

The assistant prepares the syringes for centrifugation during the simultaneous fat harvesting procedure. They are sealed with a screw top (Fig. 1b) and then centrifuged in batches of six (Fig. 1c) for 20 seconds at 3200 rpm.

Centrifugation separates the harvested fat into three layers (Fig. 1d):

• the top layer of oily fluid containing chylomicrons and triglycerides resulting from cell lysis,
• the lower layer of blood residues and serum, as well as the infiltration fluid,
• the middle layer of purified fat. This is the useful layer, which will be injected. The other two layers are discarded, the lower layer simply by removing the top, the upper layer by pouring off the oil which covers the middle layer.

The team must be well organized so that the fat can be prepared efficiently and rapidly. Using a three-way stopcock, the purified fat can be pooled in 10 ml syringes, by transfer from one syringe to another (Fig. 1e).

We use infiltration with diluted Ropivacaine at the end of the harvest to control pain in these sites during the first 24 hours. At the end of the procedure, a compressive Elastoplast dressing is applied for five days.

Fat transfer

At the recipient site on the breast, if previous scars are already present, we try to make an incision along the same lines. Several incisions are made in order to create a honeycomb of multiple microtunnels for fat transfer. Two of them are usually placed in the submammary fold, two in areola and one is often in the décolleté area. The incisions are usually made with the sharp bevel of a 17-gauge trocar. This makes an adequate incision while limiting scar consequences, which will be shaped as a hole and virtually invisible (Fig. 2a).

Purified fat is transferred directly to the breast region using 10ml syringes with special 2mm transfer cannulas (PLA188, PLA189, Pouret Medical, Clichy, France). Fat is injected in small quantities, in the form of fine cylinders resembling spaghetti (Fig. 2b). Microtunnels must be created in many directions. Transfer is done from deep to superficial plane. Good spatial visualization is necessary to form a sort of three-dimensional honeycomb, to avoid creating areas of fatty pools, which could result in fat necrosis. On the contrary, each microtunnel must be designed to be surrounded by well-vascularized tissue. It is necessary to know how to overcorrect the quantity of fat injected, if it is allowed by recipient tissues, as absorption of about 30–40% of the transferred volume can be expected.

When the recipient tissues are saturated and cannot absorb additional fat, it is useless to continue, because of the risk to induce areas of fat necrosis. It is better to plan an additional session rather than disregard saturation of the tissues. Incisions are sutured using very fine suture material.

Technique of multiple fasciotomies performed with 17-gauge trocar is one of the advancement of lipomodelling technique. Fasciotomies may release scars, enable moving the submammary fold downwards and sculpture the lower part of the breast if required (tuberous breast) (Fig. 2c).

Postoperative care

Pain in the harvesting areas resembles pain after liposuction and it is greater than in recipient breast areas. Patients complain of pain for 48 hours, which can be treated with ordinary analgesics. Infiltration of harvesting areas by diluted Ropivacaine helps to control pain during the first 24 hours. Class 1 analgesics are prescribed for about two weeks.

In the harvesting areas, compressive Elastoplast dressing is left for five days. An abdominal supporting belt may be advisable for six weeks but it is not prescribed systematically. Bruising is very marked and persists for about three weeks. Postoperative oedema subsides totally or almost totally in three months. To accelerate absorption of oedema, we ask patients to massage their harvesting sites with a circular motion.

In the breast, bruising resolves in about two weeks. Oedema resulting from the procedure resolves in about one month. During the first three post-operative months, 30–40% of the transferred volume is gradually lost, but the patient may have the impression that she has lost about 50% because of the oedema, as she sees the result the day after the procedure when the breast is most swollen.

LONG-TERM FOLLOW-UP

Based on the first author’s personal experience of 1440 interventions from 1998 to May 2012, and with a 14-year follow-up of the first patients, reliable indications on long-term follow-up can be given.

Clinical follow-up

All patients were clinically followed up and reviewed after 15 days, 3 months and 1 year. Photographs were taken at each visit. A detailed follow-up protocol was used, the goal of which was to assess the quality of the result from the patient’s and the surgeon’s viewpoint, patient satisfaction and any adverse effects or complications.

The results were considered very good or good in the majority of the cases. Very few results were considered moderately good and none as poor. The percentage of good or very good results depends on the sub-population studied in relation to the indications. For example, out of 200 breast reconstructions with extended latissimus dorsi flap and lipomodelling, there were 20% of patients satisfied or 80% of patients very satisfied with the results and 4,5% were rated by the clinical team as satisfactory and 95,5% as very satisfactory (no poor results were reported) (15). In case of the lipomodelling correction of the consequences of conservative management there were 50% very good, 40% good and 10% moderate results (21).

Radiological follow-up

We carried out three radiological studies (mammography, ultrasound, MRI): imaging of breasts reconstructed by autologous latissimus dorsi flap and lipomodelling (16), imaging of conservatively managed breasts after lipomodelling (22), and imaging of breasts augmented by lipomodelling (asymmetry, tuberous breasts, Poland syndrome) (23). Our findings have shown that if lipomodelling was carried out in accordance with modern principles of fat transfer, it had no effect on breast imaging. The prerequisite to achieve these results is a collaboration of an experienced surgeon with a specialized radiologist.

Imaging in the majority of reconstructed breasts was normal, with some images of oily cysts and fat necrosis. All of the images demonstrated benign lesions that could be easily distinguished from suspicious lesions. Abnormal images were essentially oily cysts, occurring in 15% of cases. The most complex situation concerned lipomodelling for the consequences of conservative management, since this population develops fat necrosis already in about 20% of patients following conservative management, and lipomodelling doubles this rate by generating mainly oily cysts and sometimes more complex lesions of fat necrosis. Due to the spontaneous local recurrence rate of 1.5% per year, follow up must be careful. We believe that this indication should be restricted to multidisciplinary teams working with radiologists. Radiological follow-up of breast augmented with fat grafting is not problematic – microcalcifications were observed in 16% of mammograms; macrocalcification in 9%; well focused images of cystic lesions in 25%. There was no significant difference between breast density before and after fat injection demonstrated in our previous retrospective study (23). Others papers showed no statistically significant differences between the number of these lesions in the breast after fat transfer and in the breast after a reduction mammoplasty, which is a widely accepted procedure (8).

Oncological long-term follow-up

14 years of oncological follow-up have not revealed an increased risk of local recurrence after mastectomy or after conservative management. Oncological outcome of 646 lipofilling procedures in 513 patients was evaluated in a recent multicenter study (24). 370 mastectomy and 143 breast conservative surgery patients were included (405 of them (78.9%) had a diagnosis of invasive carcinoma and 108 (21.1%) of carcinoma in situ). The overall oncological event rate was 5.6% (3.6% per year). Locoregional event rate was 2.4% (1.5% per year). A prospective clinical registry including high volume multicentre data with a long follow-up is warranted to demonstrate the oncological safety. Until then, lipofilling should be performed in experienced hands and a careful oncologic follow up protocol is advised.

There are no studies to show a higher risk of breast cancer developing after lipomodelling of otherwise healthy breast (breast augmentation, tuberous breasts, Poland syndrome) (25).

EVALUATION OF THE SUCCESS RATE

The success rate is fairly easy to evaluate by clinical examination, the patient’s opinion, and comparison of the photographs taken at each consultation with previous photographs. 30–40% of the volume gained by fat transfer is gradually lost after the first lipomodelling session. Volume is stable after 3 to 4 months and remains stable if the patient maintains constant weight. If the fat harvested is very oily (a very high percentage of oil after centrifugation), absorption may be higher (40–50%) and may continue over a longer period (up to 5 to 6 months). If there is a second fat transfer, absorption is lower (20–30%) (26).

If the patient loses weight, the volume of transferred fat decreases and the resulting smaller breast size may lead to asymmetry. It is therefore important for the patient to understand that she must maintain a stable weight. On the other hand, if she gains weight, breast volume increases in correspondence with the fat from the adipose deposit. When a second session is required to obtain sufficient fullness, absorption seems to be lower, between 20 and 30%.

Very long-term evaluation (5 or 6 years) confirms that volume remains stable. If breast asymmetry returns after weight loss (for example after discontinuation of anti-hormonal treatment as adjuvant therapy of breast cancer), a complementary lipomodelling session can easily be performed. This technique thus offers a flexibility and precision for long-term revision that is much appreciated by the patients (19).

COMPLICATIONS

Irregularities at the donor site may be due to uneven harvesting of the fat deposit, therefore harvesting is sometimes supplemented with liposuction in order to improve the result and to achieve greater patient satisfaction. The majority of patients are satisfied by the loss of excess fat, and this secondary advantage probably contributes to the very high satisfaction rate with this technique.

Local infection occurred in only one of the 1440 lipomodelling procedures. This was seen as redness around the navel and was treated without difficulty by antibiotics and local application of ice, with no long-term consequences.

In the breast, the scars must be well placed, in the submammary fold or in its axillary prolongation, or in the areolar region where scars are always less visible. The sternal area should be avoided due to an increased risk of hypertrophic scarring, presenting as small red hypertrophic punctate scars. The incisions are usually virtually invisible.

10 infections occurred among the 1440 lipomodelling procedures of the breast and chest wall. They presented as redness of the breast. Removal of sutures, topical treatment, antibiotics and the application of ice completely resolved the problem with no impact on the final result.

We had one case of intra-operative pneumothorax (1 case in 1440 procedures). A pleural drain was inserted and oxygen saturation returned to normal with total recovery and no later consequences. To avoid this complication, projection of the areolar region should be improved via two incisions in the submammary fold rather than via the areolar region itself.

We experienced no case of fat embolism. There could be a risk if fat was injected in a large vessel. Extreme caution is recommended in the subclavian area. In particular, in case of the breast and chest wall deformities in Poland syndrome the subclavian vessels may be located lower than normally.

Local clinical fat necrosis is observed in 3% of cases if lipomodelling is performed by an experienced surgeon. The risk may be higher during the surgeon’s early experiences. In these cases, the recipient areas were probably oversaturated by large amount of fat. When the recipient tissue is saturated with fat, the surgeon should not continue with application of fat, since there is a risk of fat necrosis development. Such areas have typical features: mild tenderness and they are stable over time or gradually decreasing. Any increase in the size of the hard swelling, even in a reconstructed breast, should be subject to microbiopsy performed by a radiologist in order to rule out a malignant change (19). 

INDICATIONS

Lipomodelling of the breast and chest wall is a technique, which currently has numerous indications. After breast reconstruction, it can be used whenever a localized defect requires correction or additional volume. The décolleté area is ideal for fat injection. Lipomodelling improves the volume, shape, projection, feel and silhouette of the breast. After flap reconstructions, fat transfer can add considerable volume and it preserves the entirely autologous nature of the reconstruction. In breast and chest wall deformities, fat injection enables to achieve very natural reconstructions, without an implant or a flap, that cannot be obtained with conventional techniques. In aesthetic surgery of the breast, fat transfer eliminates the need for an implant (augmentation, mastopexy with a slight lack of fullness of the upper pole of the breast) or can correct certain defects of implant augmentations.

Lipomodelling after autologous latissimus dorsi breast reconstruction

Autologous reconstruction avoids the complications of implants and the flap can be adjusted to form a breast resembling the opposite breast that will be stable over time and will be integrated better into the patient’s body image. The autologous latissimus dorsi flap (11, 12, 13, 14, 16) has gradually replaced the abdominal flap reconstruction over the last ten years in our department, as the postoperative course is simpler and it makes better use of local thoracic tissue, avoiding a patch effect on the breast. Lipomodelling of a breast reconstructed by autologous latissimus dorsi flap offers numerous advantages: the reconstruction is still entirely autologous, cost is relatively low, the technique is reproducible and the procedures can be repeated if the result is not adequate, the breast has a natural appearance and feel and it is symmetric to the opposite breast, and finally there is the secondary advantage of removing patient’s displeasing fat by suction. Combination of abdominal advancement flap with latissimus dorsi reconstruction may reduce the number of horizontal scars (to only one) in secondary cases before lipomodelling (27). An immediate nipple reconstruction may be performed in one session together with immediate breast reconstructions before lipomodelling (14).

The autologous latissimus dorsi flap is the most suitable tissue to receive fat transfer as it is very well vascularized and very large quantities of fat can be injected. Mean volumes of 200 ml and up to 450 ml per breast and per session in a single session have recently been injected with very good results. The autologous latissimus dorsi flap can now be considered to be an auxiliary method that prepares the breast recipient site for future lipomodelling. We can proceed with lipomodelling quite early (after 3 months), before muscle atrophy is maximal, in order to take the advantage of the volume effect, which allows the area to accept sufficient fat.

This technique is well accepted by the patients, who can see its efficacy and clearly understand its concept. The morphological results are objectively considered as very good (Fig. 3) and the patients are very satisfied with this procedure, which improves the reconstructed breast and reduces unaesthetic fat deposits. From our experience, the autologous latissimus dorsi flap in combination with lipomodelling now makes implant-free reconstruction possible in the vast majority of cases (15, 22, 23). Only few patients with no adipose deposits suitable for harvesting cannot benefit from this technique.

Lipomodelling of the implant-reconstructed breast

The fat may be transferred to the décolleté area (upper medial part of the breast), where lipomodelling is mainly intrapectoral. When lipomodelling is performed during replacement of an implant, fat is injected between the skin and the capsule. Laterally, fat is injected between the skin and the capsule and this can only be done when the implant is exchanged. The best results are obtained when lipomodelling is combined with implant replacement. Smaller quantities are injected, from 50 to 150 ml. As the tissue is less well vascularized than the autologous latissimus dorsi, it must be slightly less saturated with fat to ensure satisfactory survival of the transplant.

The results in our series revealed no complication inherent to this technique, bearing in mind that if lipomodelling approaches close to the implant, we advise that it should be systematically exchanged to avoid the risk of leaving an implant that could have been damaged by the transfer cannula (11, 20, 28). We found that the technique was well accepted by the patients and that both patients and the surgeons were highly satisfied. It does in fact provide results that could not be obtained by the use of an implant alone. Lipomodelling seems to reduce the risk of capsular contracture, but as yet we have no statistical evidence.

Lipomodelling of the TRAM and DIEP flap reconstructed breast

Although numerous authors consider the TRAM flap as the technique, which gives the best results in breast reconstruction, defects may also develop after its use. These include asymmetry of volume, lack of projection or a defect of the décolleté related to atrophy of the upper part of the pectoralis major muscle following the joint effect of axillary dissection and radiotherapy of the chest wall.

We used lipomodelling to breasts reconstructed with a TRAM flap in our own or in other patients. During secondary revision, we now perform intrapectoral lipomodelling and lipomodelling of the flap, insisting on the areas which lack fullness. In some cases, lipomodelling aiming to increase the overall volume of the flaps was carried out without any particular difficulty. We should keep in mind that a little less fat should be injected than with an autologous latissimus dorsi flap, as the former is not so well vascularized and the risk of fat necrosis may be higher.

In my own experience, I have not observed any complication inherent to this technique and our objectives were attained: improvement of the overall shape of the breast and improvement of the upper décolleté area (19).

Breast reconstruction by repeated lipomodelling

We developed a protocol for breast reconstruction by the use of lipomodelling alone. At the present time, it is exclusively used in patients with a small opposite breast and with suitable fat deposits (typically a patient with a slim upper body and a fatter lower body). The technique consists of reconstructing the breast in several stages, using only fat injection. In the indications defined above, three to four lipomodelling sessions are required to reconstruct a breast to match the volume of the opposite breast. During the last three years, we have expanded our therapeutic protocol with the use of vacuum external breast pre-expansion with the BRAVA^® system. In our initial experiences, the use of external breast pre-expansion seems to be very effective and facilitates lipomodelling by formation of tissue oedema. This therapeutic protocol is being evaluated and will no doubt be reserved for particular reconstructions in patients with small breasts or for repair of failed reconstructions (29).

Other applications in breast reconstruction

When the skin is very thin or damaged by radiotherapy and there is a risk of skin necrosis during breast reconstruction, it is possible to carry out preparatory lipomodelling a few months beforehand, injecting 80 to 120 ml of fat in the thin damaged thoracic tissue. This improves skin trophic condition and avoids necrosis, a complication always difficult to manage even in autologous breast reconstructions.

Lipomodelling for the correction of the consequences of conservative treatment

When lipomodelling is proposed to correct the consequences of conservative treatment (after lumpectomy and radiotherapy) it is subject to a very strict protocol. In this indication, there is in fact a high risk of a coincident new cancer or local recurrence of the primary cancer (24). The protocol must be very strict to limit the risk of coincident cancer, which could potentially lead to medicolegal consequences if the patient has not been satisfactorily informed (30). The protocol includes a detailed imaging investigation (22) with mammography, ultrasound and MRI performed by a radiologist specializing in breast imaging. Lipomodelling is generally performed based on an agreement of the specialized radiologist and oncologist who follows the patient. Similarly, one year after lipomodelling, further imaging is done with mammography and ultrasound. If any suspicious image is present, the radiologist performs a microbiopsy. There was a study (22) published which included 42 patients with the consequences of conservative management who underwent lipomodelling and were included in a detailed radiological protocol. The study concluded that lipomodelling was a considerable advance in the therapeutic choice for management of moderate consequences of conservative management. It restores the breast curves and suppleness that no other surgical technique had previously achieved (Fig. 4). This is however the most challenging indication and we recommend that a multidisciplinary team managed these patients (19, 31).

Poland syndrome and lipomodelling

Correction of the breast and chest wall deformities in Poland syndrome is still a challenge for the plastic surgeon. Lipomodelling appears to be very useful in this condition (Fig. 5) and enables to achieve breast reconstruction of excellent quality after simple, repeated procedures (6, 30) with very limited scar sequelae. We treated 25 patients using this technique, 23 by lipomodelling alone and two by lipomodelling to supplement a flap. In this series, an average of three sessions was required to obtain the desired result, with a mean of 244 ml injected during each session. The results are very interesting and a breast that is almost identical to the opposite breast can be reconstructed. This technique appears to revolutionize the management of breast and chest wall deformities in Poland syndrome (11, 20, 32, 33).

Pectus excavatum and lipomodelling

Pectus excavatum is a complex deformity with hollowing of the anterior sternocostal wall. It usually has little or no functional impact and in most cases the problem is essentially morphologic and aesthetic, with considerable deformity if the condition is very marked or lateral. Fat transfer techniques, used alone, provide satisfactory correction for mild to moderate forms (11, 19, 20, 33), or in association with a custom-made rigid implant (based on a 3D CT scan) in major forms. Analogically, lipomodelling is an effective treatment of the chest wall deformities after pulmectomy, chest wall injuries or burns.

Tuberous breasts

Tuberous breast is a deformity of the base of the breast, with onset at puberty when breast development begins. Various surgical approaches have been described and a wide range of techniques exists to obtain the best possible result. Among them, lipomodelling (11, 19, 20, 33) can correct the lack of volume and improve the base and the shape of the breast. The best indications include unilateral hypoplastic tuberous breast and lack of fullness of the upper pole of the breast. Two fat transfer sessions are usually required. However, implants are still the treatment of choice for tuberous breasts with bilateral hypoplasia. Coleman (25) also demonstrated very pleasing aesthetic results in tuberous breasts treated by fat injection.

Breast aesthetic surgery

Lipomodelling in aesthetic surgery is developing fast. Our studies have shown that if lipomodelling is carried out according to the technique we have described in this chapter, it does not generate radiological images which cause problems in differential diagnosis with breast cancer or in radiological follow-up for radiologists who are specialized in breast imaging (22, 23). The principal radiological risk is that breast cancer may occur coincidentally with lipomodelling. In order to reduce this risk, imaging (mammography and ultrasound) is carried out before lipomodelling by a specialized radiologist in order to ascertain the absence of a suspicious lesion. If there is any doubt, lipomodelling is deferred or contraindicated. The radiologist must provide approval before lipomodelling and share responsibility for it. The patient gives a written consent to attend for the same investigations by the same radiologist one year after the procedure. If the radiologist finds a suspicious lesion on imaging in one year, microbiopsy is systematically performed in order to establish a definitive diagnosis. In this indication, the information given to the patient is particularly comprehensive and she must carefully read the information leaflet provided during the preoperative consultations.

Aesthetic lipomodelling is a treatment option for correction of the imperfections of mammaplasty and the imperfections and complications of implants, for aesthetic breast augmentation and enhancement of fullness of the décolleté. The indications of lipoaugmentation differ from those of implant augmentations. Lipoaugmentation is suitable for patients who want moderate increase of breast volume, or who want to restore fullness they had before weight loss or pregnancy. The ideal patient is a young woman with a slim upper body and moderately small breasts and with sufficient regional adiposity of the lower body to allow one or even two lipomodelling sessions. In this indication, it is of great importance to gain visible improvement at the harvesting site. It is essential to make sure that the patient has effectively achieved a stable weight (if she loses weight, she will also lose much of the benefit of the procedure).

Asymmetry is a difficult problem when one breast has satisfactory fullness and perfect shape and the other is hypoplastic. Conventionally, an augmentation implant is inserted in the underdeveloped breast. While the initial result is usually good, asymmetry of shape and volume often reappears several years later. In this indication, lipomodelling yields a breast very similar to the normal breast, which will change naturally over time, in particular as regards to ptosis. Depending on the degree of asymmetry and hypoplasia, one to three fat transfer sessions will be needed for an optimal result (two sessions are generally sufficient).

CONCLUSION

Lipomodelling is a major development in plastic, reconstructive and aesthetic surgery of the breast, and we consider it to be one of the major advances of the last 20 years. The technique is now well defined and the complication rate is very low. Clinical long-term follow-up shows that the morphological result regarding volume is stable 3 to 4 months after the procedure with the condition that the patient’s weight remains constant. Because of the low complication rate, very good results obtained, excellent acceptance of the technique by the patients, lipomodelling has completely modified our indications in plastic, reconstructive and aesthetic surgery of the breast.

Address for correspondence:

Dr. Libor Streit

Department of Plastic and Aesthetic Surgery

Berkova 34

612 00, Brno

Czech Republic

E-mail: streit@fnusa.cz