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Conventional breast reconstruction techniques are found here:
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Newest technique in breast reconstruction: Reversed Expansion
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To reconstruct the entire breast after mastectomy we have been relying until now on two main reconstructive techniques, placement of breast implants and microsurgical free tissue transfers or free flaps like the DIEP flap.
Today there is a new technique for full breast reconstruction in selected patients and it is based on the principles of lipofilling. Lipofilling is now a well-established procedure to transfer fat cells and its supportive environment (the extra-cellular matrix) from one place in the body to another. We have been using and investigating this technique over the last 15 years with great success in both aesthetic and reconstructive surgery throughout the entire body. |
The principle of lipofilling consists first of all of aspirating small clusters of fat cells (<3mm) by the technique of liposuction with small diameter cannulas. Fat is taken from areas where fat accumulates which is mostly at the level of abdomen, love handles, and the thighs (front, side or inside). Next, the fat cells and supporting cells are isolated by centrifugation. Oily and watery components are removed. The isolated cells can now be re-injected in a different area of the body where volume is needed (so-called volume effect). Through more advanced techniques, stem cells derived from the fatty tissue, can separately be isolated and then used for more regenerative purposes (so-called regenerative effect). Both can also be mixed. Because this is your own tissue, no rejection can occur.
What is the difference between a free flap and lipofilling?
The main challenge is how to create a large 3D tissue construct that consists of adipocyte clusters or in other words how to perform a breast reconstruction with lipofilling only?
Patients who are not ready for a free flap reconstruction and want to avoid a large scar can be candidates for reversed expansion.There are two important conditions however to be eligible for this technique:
Breast cancer is a glandular cancer that does not primarily involves the overlying skin. In more and more cases, the breast skin can be preserved without increasing the oncological risk. Only when the tumor is close to the skin or is very extensive, skin may need to be taken away. This means that today we can limit ourselves to remove the breast gland and leave the breast skin with its underlying subcutaneous fat. Often only a single incision is necessary, limiting external mutilation of the skin.
The pocket or cavity that is created after glandular removal has traditionally been filled up by a fixed volume breast implant corresponding to the volume of the original breast when no breast skin was removed. Historically, breast expanders have only been used in cases where big parts of breast skin were removed and where the remaining skin had to be stretched to accommodate the final breast implant in a second procedure.
In this new technique of ‘reversed expansion’ we have thrown things around a bit.
As we cannot fill up the entire cavity of a mastectomy with lipofilling (remember only small amounts of fat transfer will survive with each procedure of lipofilling), we will instead place a completely filled up expander in the mastectomy cavity during the same procedure as the mastectomy (in front of the pectoral muscle) with a volume that corresponds to the volume of original breast.
The expander however, is not used to “expand” but actually to create a vascular bed for the future fat grafts and to be deflated in a later phase. The insertion of an expander or implant not only fills up space but also induces a well-vascularized autologous-based capsule around the implant that functions as a vascular source. Targeted fat grafting of the space in between the outer skin envelope and the capsule inoculates the fat grafts in close proximity to the young vascular plexus that will nourish the grafted material. This space is a well-circumscribed niche that prevents oozing of the fat grafts in the space occupied by the expander and provides the perfect feeding ground for newly injected fat cells.
The procedure of reversed expansion takes several interventions:
What are the advantages and disadvantages of this new technique?
As you probably understand by now, the main disadvantage of this technique are the repeated surgical procedures and the long period of time before the final volume of a breast can be achieved. Unfortunately, many health care insurances refuse to reimburse this new technique. We advise you to inform yourself around the financial aspects of this procedure.
The great advantage of this technique is that at all times, the original volume of the breast is maintained and that the patient can keep on wearing her original bra without the outer world noticing. Also, the avoidance of scars and the improvement of body contour are important benefits. With this, a mastectomy will be less of a psychological burden.
The future?
In the next years, 3D tissue engineering will probably allow us to generate large volume constructs created in a laboratory environment, but research in this domain is only in its first steps…
Examples
What is the difference between a free flap and lipofilling?
- With a free flap, large amounts of tissue are transferred in one procedure. Survival of the tissues depends on the connection between the artery and vein of the flap to an artery and vein at the recipient site.
- Possible disadvantages: need for microsurgery, longer surgical time, possibility of total flap loss (<0,5%) and long scars at the donor site
- Advantages: large volume transfers possible in one single operation, no need for multiple surgical procedures, the only way to create natural looking results when large areas of breast skin have been removed during the mastectomy procedure.
- With lipofilling, the cells will survive by ingrowth of tiny capillaries, just like a skin graft will survive on an extensive burn wound.
- Important disadvantage: through this type of survival, about 40 to 50% of the transferred cells will die. Also, limited amounts of volume can injected with each procedure, making multiple (small) procedures necessary if large volume transfers want to be obtained (like for a breast). Skin cannot be transferred or created with this technique.
- Important advantages: no additional scars, no prolonged and complicated surgery, improvement of the shape of the body where the fat has been taken away.
The main challenge is how to create a large 3D tissue construct that consists of adipocyte clusters or in other words how to perform a breast reconstruction with lipofilling only?
Patients who are not ready for a free flap reconstruction and want to avoid a large scar can be candidates for reversed expansion.There are two important conditions however to be eligible for this technique:
- There needs to be sufficient fat tissue elsewhere in the body
- The majority of breast skin has to be preserved during the mastectomy procedure
Breast cancer is a glandular cancer that does not primarily involves the overlying skin. In more and more cases, the breast skin can be preserved without increasing the oncological risk. Only when the tumor is close to the skin or is very extensive, skin may need to be taken away. This means that today we can limit ourselves to remove the breast gland and leave the breast skin with its underlying subcutaneous fat. Often only a single incision is necessary, limiting external mutilation of the skin.
The pocket or cavity that is created after glandular removal has traditionally been filled up by a fixed volume breast implant corresponding to the volume of the original breast when no breast skin was removed. Historically, breast expanders have only been used in cases where big parts of breast skin were removed and where the remaining skin had to be stretched to accommodate the final breast implant in a second procedure.
In this new technique of ‘reversed expansion’ we have thrown things around a bit.
As we cannot fill up the entire cavity of a mastectomy with lipofilling (remember only small amounts of fat transfer will survive with each procedure of lipofilling), we will instead place a completely filled up expander in the mastectomy cavity during the same procedure as the mastectomy (in front of the pectoral muscle) with a volume that corresponds to the volume of original breast.
The expander however, is not used to “expand” but actually to create a vascular bed for the future fat grafts and to be deflated in a later phase. The insertion of an expander or implant not only fills up space but also induces a well-vascularized autologous-based capsule around the implant that functions as a vascular source. Targeted fat grafting of the space in between the outer skin envelope and the capsule inoculates the fat grafts in close proximity to the young vascular plexus that will nourish the grafted material. This space is a well-circumscribed niche that prevents oozing of the fat grafts in the space occupied by the expander and provides the perfect feeding ground for newly injected fat cells.
The procedure of reversed expansion takes several interventions:
- In the first step, the breast gland is removed and the expander is introduced fully expanded.
- Three to six months after insertion of the expander, once a well vascularized matrix is formed around the expander, a first session of lipofilling is performed. As limited volumes will survive, especially when the layer between the skin and the expander is still thin, small volumes will be transferred in the beginning.
- Lipofilling sessions and serial deflations can be repeated every 3 to 6 months. With each session, the expander is deflated according the maximum volume of lipofilling that can be performed within that same session. This way, there is no tension by the outer skin on the grafted fat cells and the total volume of the breast always remains more or less the same (taking into account temporary surgical edema) and hereby limiting the physical impact for the patient. Each time fat is injected, more fat will survive in this layer around the expander, allowing to inject even more fat during the next session. Outer compression needs to be avoided during the first 3 weeks after transfer to allow capillaries to grow into the fat grafts and to maximize survival
- In general, 3 to 7 sessions may be needed to get to the final volume depending on the original size of your breast. Once sufficient fat has been injected and has survived, the expander is removed in a final session. Every procedure takes about 30 to 60 minutes and can be performed under deep sedation. Day clinic stay is recommended.
What are the advantages and disadvantages of this new technique?
As you probably understand by now, the main disadvantage of this technique are the repeated surgical procedures and the long period of time before the final volume of a breast can be achieved. Unfortunately, many health care insurances refuse to reimburse this new technique. We advise you to inform yourself around the financial aspects of this procedure.
The great advantage of this technique is that at all times, the original volume of the breast is maintained and that the patient can keep on wearing her original bra without the outer world noticing. Also, the avoidance of scars and the improvement of body contour are important benefits. With this, a mastectomy will be less of a psychological burden.
The future?
In the next years, 3D tissue engineering will probably allow us to generate large volume constructs created in a laboratory environment, but research in this domain is only in its first steps…
Examples
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Example of a reversed expansion technique.
Left/above: After mastectomy and removal of both nipples breast implants were placed. Patient complained about chronic pain and firmness. Important capsular contracture was noticed. Right/below: after serial deflation and lipofilling (5 sessions), a nipple reconstruction and areolar tattoo was performed. All foreign material (implants) were removed and a permanent result was obtained. A soft and natural feel took place for the pain and firmness. |
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Second similar case showing the 'artificial' look of the implant reconstructions. Right/below: 4 sessions of serial deflation and lipofilling resulting in a natural shape and desired volume |