Lipofilling and Oncoplasty

Funding Sources/Financial Disclosures

This work was not supported by any external funding. Dr. Alexandre Mendonça Munhoz is a consultant to Motiva/Establishment Labs Corporation.

Contributor’s Statement

Dr. Alexandre Mendonça Munhoz is the principal investigator of this study. The principal investigator made significant contributions to the conception and design of this study and made substantial contributions to the acquisition, analysis, interpretation of data, and manuscript preparation. The author revised the article for intellectual content, gave final approval of the version to be published, and has sufficiently participated in the work to take public responsibility for appropriate portions of the content.

Introduction

Breast-conserving surgery (BCS) for early breast cancer treatment continues to be one of the most frequently performed oncologic surgeries worldwide. The introduction of the oncoplastic approach as well as new surgical techniques have led to widespread acceptance of immediate and delayed reconstruction following BCS.

Advances in oncoplastic surgical techniques have reduced surgical morbidity and can thus preserve breast shape and lead to better aesthetic outcomes. Even though most partial mastectomy defects can be treated with primary closure, the outcome may be aesthetically unpredictable and result in contour abnormalities. Oncoplastic techniques are classified as volume displacement or replacement procedures. There is no consensus as to the best approach, and the criteria for selecting an optimal technique are determined by the surgeon’s experience and the size of the defect relative to the remaining breast. The advantages of oncoplastic breast reconstruction should include reproducibility, low interference with oncologic treatment, and acceptable long-term results. Surgical planning should include an assessment of patient preference, addressing individual reconstructive requirements and to custom tailor each individual reconstruction.

Even though it is widely used today, lipofilling or lipomodeling (more specifically described as autologous fat grafting/transfer, AFG) is an old concept. Despite the advantages AFG offers, its use in reconstructing BCS defects is controversial, particularly with regard to aesthetic results and oncologic outcomes. As of this writing, few clinical studies have assessed outcomes after AFG to an unfavorable recipient site, and studies focused on breast conservation with immediate AFG are similarly lacking. Some authors maintain that this is because AFG is usually performed by plastic surgeons, whereas oncologic/breast surgeons perform BCS. Today, a new generation of oncoplastic surgeons is emerging with training in both breast and plastic surgery, and the number of studies on this topic is expected to increase in the coming years.

Although reconstruction following BCS has a high rate of patient satisfaction, some patients may present unsatisfactory results and require surgical revision. In our experience, many of these reoperations are required for problems related to the soft tissue such as local irregularities and implant visibility/rippling rather than reconstruction failure. As with total breast reconstruction, there has been a resurgence in the use of AFG following BCS for a variety of indications over the past 10 years. Although refinement in AFG procedures has improved reproducibility, a standardized technique is lacking, and its relevance as an associated technique has yet to be investigated. It can be assumed that if AFG, BCS, and oncoplastic reconstruction are equally reproducible and involve similar risk and surgical time, the feasibility of combining all of these techniques is now realistic.

The objective of this chapter is to provide an overview of BCS reconstruction incorporating oncoplastic techniques and AFG. Although all these techniques are well-studied procedures, few detailed clinical reports specifically address the operative planning, outcomes, and complications following AFG. As a result, this chapter presents a detailed description of our method, including the preoperative evaluation and intraoperative care for patients undergoing primary and secondary reconstruction. The surgical technique, advantages, and limitations are also discussed. When combined with clinical expertise, the evidence provided in this chapter will help plastic surgeons better counsel and educate patients to achieve reproducible and predictable aesthetic outcomes.

Patient Selection