Keywords breast reconstruction - latissimus dorsi - fat-grafting - implant failure - postoperative
complication - lipofilling
Introduction
Since the early 2000s, breast reconstruction with implants has prevailed over autologous
breast reconstruction (ABR).[1 ] Today, 80% of breast reconstructions are implant-based breast reconstructions (IBBRs).[2 ] This increase in IBBR has been associated with a number of factors, including indications
for contralateral mastectomy, a better surgical performance, and less demanding surgical
skills.[1 ] Nevertheless, indications for radiotherapy in breast cancer are growing.[3 ]
[4 ] The side effects of radiotherapy in IBBR are widely associated with a higher rate
of reconstructive failure,[5 ]
[6 ] being significantly higher than in those who have undergone ABR.[7 ] This scenario has resulted in an increased number of patients who have initially
undergone IBBR before experiencing serious complications. Sometimes, these implant
complications occur repeatedly after successive prosthetic replacements until the
patient rejects further implant surgery or decides to convert to ABR.
ABR using fat-augmented latissimus dorsi (FALD), originally described by Santanelli
di Pompeo et al[8 ] in 2014, has become popular in recent years.[9 ]
[10 ]
[11 ] It is a totally autologous reconstructive procedure which presents few complications
and is based on well-known techniques: harvesting a latissimus dorsi (LD) flap and
fat-grafting procedures.
The aim of this study was to evaluate the safety, rates of complications, and reconstructive
failure using the FALD technique in patients with prior failure of IBBR, in an attempt
to offer them a safer reconstructive procedure.
Materials and Methods
A prospective case series study was performed from May 2014 to December 2020. The inclusion criteria were women
with a failed IBBR and a subsequent conversion to ABR using FALD. A minimum 1-year
follow-up period after ABR was considered. A magnetic resonance imaging (MRI) or ultrasound
(US) was performed at least 6 months after the end of the ABR in all of the patients.
Patients who were not in compliance with the above criteria were not eligible for
inclusion in the study. Patients who underwent hybrid reconstruction were excluded
from the study. A study protocol was applied on every patient, focusing on their previous
reconstructive history, the characteristics of conversion to ABR, and the development
of potential complications. Major complications were defined as being when the patient
required surgery or hospital admission for their treatment. Minor complications were
considered when only outpatient and conservative treatment was necessary. Reconstructive
failure was defined as when a new surgical procedure was required, including implant
removal, implant exchange, or ABR conversion.
Surgical Technique ([Video 1 ])
Video 1 Key steps of the fat-augmented latissimus dorsi (FALD) technique. From the extraction
of adipose tissue by liposuction to the grafting of the processed tissue in breast
reconstruction, including LD flap harvesting and adipose tissue centrifugation.
The first part of the intervention should be performed with the patient in a decubitus
supine position and consists of obtaining the fat graft by liposuction and the preparation
of the mastectomy area. Previous scar tissue is removed. Implants removal and capsulectomy
are realized if any implant problem is present. Subsequently, the patient is placed
in the lateral decubitus position for the harvest of LD flap while the liposuctioned
fat is processed. Finally, the patient is returned to the decubitus supine position
for fat grafting and the insetting of the flap.
We prefer the abdominal region as the fat graft donor site. Liposuction is performed,
after infiltration with 1:1,000,000 epinephrine saline solution, with a Mercedes-type
cannula (3 mm; 32 cm). The lipoaspirate is centrifugated for 3 minutes using a fixed-rotor
centrifuge (Thermo Scientific MediLite, Austin, Texas, United States; 3,100 revolutions
per minute; 1,228 g ) and serum and supernatant are disposed of. The syringes employed in the centrifugation
process (10-mL Luerlock syringes, B-Braun, Melsungen, Germany) are directly employed
in the subsequent fat grafting ([Video 1 ]).
The decision to make a LD flap with an external skin island depends on the amount
of skin on the breast to be reconstructed. If there is good quality skin, we prefer
to deepithelialize the skin island of the flap to avoid different aesthetic units
in the breast. We rarely use a pure muscle flap and prefer to deepithelialize the
island of the myocutaneous flap providing extra volume. We always draw the skin island
approximately 3 to 4 cm wider than the mastectomy scar to improve the natural, curved
shape of the breast. We do not perform denervation or detachment from the humeral
insertion of the muscle. When harvesting the flap, we seek to recruit as much subcutaneous
fat as possible, especially, from the lumbar area.[12 ] Once the flap has been harvested and transferred, the donor site of the flap is
sutured in layers, a Blake drain is placed, and the patient is returned to the decubitus
supine position.
The fat grafting is performed before the flap is anchored to the recipient area. We
use 16-gauge cannulas (Coleman Infiltration cannula, Style I for body-16 ga. Mentor),
to make a homogeneous “drop-by-drop” or “spaghetti-like” three-dimensional infiltration
along the LD flap, the pectoralis major muscle, and the skin flaps of the mastectomy.
Although most of the fat graft is placed in the muscular portion of the LD muscle,
sufficient grafting in the pectoralis major muscle is also important if the aim is
to achieve adequate shape and volume of the upper pole of the breast in a single operation.
Mastectomy flaps usually admit small amounts of fat graft, but makes it possible to
correct small volumetric defects.
Once the fat grafting has been completed, the flap will be adapted to the recipient
area. The lower part of the cutaneous island is always anchored along the inframammary
fold. The muscular portion of the LD flap usually overlaps the pectoralis major muscle.
If extra volume is required in the lower pole of the breast, this muscular portion
can be folded in on itself under the cutaneous island of the LD and anchored to the
thoracic wall. The recipient site is sutured in layers after careful hemostasia and
the placing of a Blake drain.
The patient should wear a specific bra and thoracoabdominal compression garments for
a month after surgery.
Statistical Analysis
Data concerning patient records were analyzed using IBM SPSS Statistics 22.0 (IBM
Corp., Armonk, New York, United States). The Kolmogorov–Smirnov goodness-of-fit test
was used to verify the normality of the distributions. The Mann–Whitney U test was employed to study correlations between nonparametric distributions. The
Student's t -test was used to study parametric distributions. Pearson's chi-square test was employed
to study the relationship between qualitative variables. Statistical significance
was considered when p < 0.05.
Results
A total of 316 ABRs using the FALD technique were operated during the study period,
with a history of IBBR failure in 61 (19%) of the cases. Fifty-six patients were finally
included in the study (5 with bilateral IBBR failure). Of the 61 reconstructions,
52% (32) were in the right breast and 48% (29) in the left. The mean age when undergoing
ABR conversion was 50.85 years (range 36–73). Mean body mass index (BMI) when ABR
conversion occurred was 28.70 kg/m2 (range 21.63–41.78), with 34% (21) of patients living with obesity.
IBBR was performed immediately after mastectomy in 67% (41) of the cases. Reconstructive
timing (immediate/delayed) was not found to be statistically related with the number
of autologous surgeries required (p = 0.92) or with the volume of fat grafted (p = 0.40).
Radiotherapy had been administered in 74% (61) of the cases. Of the 61 cases, 51%
(31) still had the breast implant when ABR was performed ([Fig. 1 ]), while in 49% (30) of the cases the breast implant had been previously explanted
([Fig. 2 ]). All cases had experienced at least one IBBR failure ([Figs. 3 ] and [4 ]). In 5% (3) of the cases the aesthetic result was unacceptable for the patient,
despite not presenting any of the aforementioned complications.
Fig. 1 (A ) Grade IV capsular contracture in a patient who had undergone a previous surgery
due to the same problem. (B ) Postoperative view 7 months after implant removal, capsulectomy, and fat-augmented
latissimus dorsi (FALD) (370 mL of fat graft).
Fig. 2 (A ) A 56-year-old patient who underwent two previous implant-based breast reconstruction
(IBBR) failures due to infection in both cases. (B ) Appearance of the reconstruction 14 months after fat-augmented latissimus dorsi
(FALD) reconstruction with 415 mL of fat graft.
Fig. 3 Reconstructive course of the patients included in the study. The majority underwent
conversion to autologous breast reconstruction (ABR) after failure of the first implant-based
breast reconstruction (IBBR). In no cases were more than three implant-based reconstructions
attempted.
Fig. 4 (A ) Patient who underwent implant-based breast reconstruction (IBBR) and postoperative
radiotherapy developing an early grade IV capsular contracture. (B ) Postoperative view 7 months after conversion to autologous breast reconstruction
(ABR) using the fat-augmented latissimus dorsi (FALD) technique (280 mL of fat graft).
A statistically significant relationship was found between cases of implant infection
and the total number of autologous surgeries needed (p = 0.02), the number of fat-grafting sessions required after FALD (p = 0.02), and the volume of fat graft employed (p = 0.01) ([Fig. 5 ]). In cases with a previous implant extrusion, statistically significant differences
were found with the total number of autologous surgeries (p < 0.001) and the number of fat-grafting sessions needed after FALD surgery to achieve
a satisfactory ABR (p < 0.001) ([Table 1 ]).
Table 1
Previous implant complications and their relationship with total autologous surgeries,
additional AFG sessions, and AFG total volume
History of Baker grade III/IV capsular contracture
History of implant infection
History of implant extrusion
Total autologous surgeries
No: 1.56 ± 305
Yes: 1.52 ± 0.5
p = 0.72
No: 1.46 ± 0.5
Yes: 1.80 ± 0.41
p = 0.02[a ]
No: 1.26 ± 0.45
Yes: 1.67 ± 0.48
p < 0.001[a ]
Additional AFG sessions
No: 0.56 ± 0.5
Yes: 0.52 ± 0.5
p = 0.72
No: 0.46 ± 0.5
Yes: 0.8 ± 0.41
p = 0.02[a ]
No: 0.26 ± 0.45
Yes: 0.67 ± 0.48
p < 0.001[a ]
AFG total volume
No: 433.31 ± 166.98 mL
Yes: 425.52 ± 155.68 mL
p = 0.69
No: 401.65 ± 152.71 mL
Yes: 515.33 ± 157.52 mL
p = 0.01[a ]
No: 374.79 ± 153 mL
Yes: 454.4 ± 158 mL
p = 0.09
Abbreviation: AFG, autologous fat grafting.
a Statistical significance.
Fig. 5 (A ) Radiated patient with two previous implant-based breast reconstruction (IBBR). (B ) Postoperative view 7 months after fat-augmented latissimus dorsi (FALD) surgery
with 260 mL of fat graft. (C ) Postoperative appearance 9 months after complementary lipofilling (220 mL) prior
to nipple-areolar complex (NAC) reconstruction.
A single autologous surgery was sufficient for the completion of the ABR conversion
in 45% (27) of the patients. No statistically significant differences were found between
patients maintaining the implant or not at the time of FALD surgery and completing
the process with a single procedure (p = 0.90). Statistically significant differences were observed between completion of
the autologous conversion in a single surgery and a previous history of breast reconstruction
failure due to implant infection (p = 0.03) or implant extrusion (p = 0.01) ([Fig. 6 ]) ([Table 2 ]).
Table 2
Studied factors and their influence on ABR in a single procedure
Autologous conversion in a single procedure (LIFG)
p -Value
No
Yes
Presence of implant at LIFG surgery
No
17
17
0.90
Yes
13
14
Initial immediate breast reconstruction
No
23
11
0.93
Yes
18
9
Obesity
No
24
10
0.35
Yes
16
11
History of radiotherapy
No
11
23
0.22
Yes
5
22
History of Baker grade III/IV capsular contracture
No
19
15
0.54
Yes
13
14
History of implant infection
No
22
12
0.03[a ]
Yes
24
3
History of implant extrusion
No
28
6
0.01[a ]
Yes
14
13
Abbreviations: ABR, autologous breast reconstruction; LIFG, latissimus dorsi and immediate
fat grafting.
a Statistical signification.
Fig. 6 (A ) Patient with three bilateral implant-based breast reconstruction (IBBR) failures
due to infection/extrusion. (B ) Postoperative view 6 months after bilateral fat-augmented latissimus dorsi (FALD)
(330 mL right, 335 mL left). (C ) Postoperative view 13 months after lipofilling (280 mL right breast, 290 mL left).
The mean volume of fat graft used to complete the ABR was 429.61 mL (range 100–755).
The mean volume employed in the FALD procedure was 310.57 mL (range 100–510). If required,
additional fat-grafting surgeries were performed an average of 8.3 (range 6–14) after
FALD. No second fat-grafting sessions were necessary in any case.
The mean length of the surgical procedure in cases of unilateral conversion was 3.17 hours
(range 2.15–4.72) and 4.63 hours (3.60–5.10) in bilateral cases.
Only 3.3% (2) of the cases developed a major complication. Minor complications arose
in 26% (16) of the cases ([Table 3 ]). Statistical significance was found in relation to obesity at the time of FALD
surgery and the development of major complications (p = 0.05), minor complications (p = 0.01), and with all of the individual complications studied (partial necrosis of
the flap p = 0.05; seroma in the donor site area p < 0.001; dehiscence of surgical wound p < 0.001; detection of nodes of fat necrosis or oil cyst upon physical examination
p = 0.03; detection of nodes of fat necrosis or oil cyst when performing imaging techniques
p = 0.05).
Table 3
Complications after ABR
Complication
% (n )
Partial skin island flap necrosis
3.3 (2)
Flap donor site seroma
14.8 (9)
Wound dehiscence
11.5 (7)
Fat necrosis nodule/oil cyst[a ]
11.5 (7)
Fat necrosis nodule/oil cyst[b ]
19.7 (12)
Abbreviation: ABR, autologous breast reconstruction.
a At physical examination.
b Ultrasound/magnetic resonance exploration.
A history of previous radiotherapy was not found to be significantly related with
the presence of major complications (p = 0.40) or minor complications (p = 0.23).
The average length of hospital stay following FALD surgery was 2.67 days (1–7) and
the mean follow-up after the last surgery was 27.25 months (range 12–59).
Discussion
The analysis of IBBR failures has a limited timeline in many of the published studies.
Follow-up periods are, in many cases, lamentably short.[13 ]
[14 ]
[15 ] However, data regarding rates of failure in IBBR, especially in radiated patients,
are remarkable. With a follow-up of only 12 months, Cordeiro et al show a reconstructive
failure rate of 11% in the group of radiated patients. Pathological capsular contracture
was not considered as a reconstructive failure in this study, but in the group of
radiated patients, it reached striking values of 34% in grade III and 6% in grade
IV.[13 ] Other recent series, such as the MROC multicenter study, show a reconstructive failure
rate between 10 and 20% when radiotherapy is administered on the definitive implant
or expander. In this study, with a follow-up period of 24 months, capsular contracture
was not studied.[15 ] Therefore, it can be seen that in some studies in which IBBR is analyzed, there
is a tendency to minimize complications arising in the form of capsular contracture.
Not considering pathological capsular contracture as a true reconstructive failure[13 ]
[14 ]
[15 ]
[16 ]
[17 ] may be due to its occurrence beyond the immediate postoperative period but does
not exclude the fact that it is a cause of discomfort, pain, or unsatisfactory aesthetic
result. In these situations, a new surgical procedure is unavoidable. In our series,
Baker grade III/IV capsular contracture was studied in depth, and the conclusion was
drawn that it is fair to consider it as a completely justified cause of reconstructive
failure taking into account the fact that 41% of the cases had to undergo surgery
again for this reason after their reconstruction had supposedly ended. Attempting
to exclude this complication as a cause of reconstructive failure when it is the most
frequent cause of reoperation in patients undergoing IBBR[18 ] seems unacceptable if what is sought is an objective assessment of the quality of
the reconstructive procedure.
It seems paradoxical that with IBBR being the most frequent method of breast reconstruction,
even more so in the context of the increasing indication of radiation therapy, there
is little published evidence on this aspect of breast reconstruction.[19 ]
Based on our own data and other published studies, it can be observed that, even today,
there are patients who undergo a mastectomy without being fully informed of the pros
and cons of the different reconstructive methods, especially in the cases with radiotherapy.
The association between IBBR and radiotherapy has shown failure rates of close to
50%.[14 ] We believe that, beyond short-term economic criteria and surgical skills, ABR presents
fewer complications, lower rates of reconstructive failure, and higher quality long-term
results.[20 ]
[21 ]
FALD reconstruction is a totally autologous, nonmicrosurgical procedure, which is
highly efficient with an exceptional reconstructive failure rate and excellent long-term
results.[8 ]
[9 ]
[10 ]
[22 ]
[23 ]
[24 ] The main limitation initially assigned to this type of ABR was whether the amount
of fat grafted in a single surgery could provide enough volume to accomplish the reconstruction
without complications. Previous studies have shown that a suitable flap adaptation
to the recipient site, together with a correct fat-grafting technique,[9 ] allows the grafting of reasonably large volumes without increasing complications,
including fat necrosis.[25 ]
[26 ] The oncological safety of lipofilling techniques has been demonstrated. Fat grafting
in a previously treated area of carcinoma has not been associated with increased recurrence
rates.[27 ]
[28 ] This, together with the great versatility of the technique, has led to the widespread
use of lipofilling in breast surgery, been employed as a method for total breast reconstruction,[28 ]
[29 ] combined with implants,[30 ] to repair the sequelae of breast-conserving surgery[31 ] or combined with different flaps.[9 ]
[32 ]
In our study, almost half of the patients (45%) required no additional surgery to
complete the reconstruction. These data show the high efficacy of the FALD technique
in providing large volumes in a single surgical procedure with a low complication
rate. The only factor related to a higher rate of fat necrosis nodes was obesity.
However, even in patients with a high BMI, the reconstructive failure rate was null.
These data support FALD as a safe technique, even in patients with obesity, in which
microsurgical ABR may present slightly increased rates of flap loss.[7 ]
[33 ]
Intramuscular fat grafting could theoretically lead to an increased risk of fat embolism,
but most of the reported cases have occurred in cases of gluteal augmentation or treatment
of genital areas. In addition, it is impossible to distinguish whether a fat embolism
is due to liposuction or the subsequent fat grafting.[34 ] Moreover, no intramuscular calcifications due to fat grafting have been observed
in the postoperative US/MRI. The fact that most of the fat graft is placed in an intramuscular
plane does not appear to affect the survival of the flap. In fact, with the aforementioned
fat-grafted volumes there were cases of muscle injury.
Data regarding surgical complications in our patients are similar to other FALD series
in which nonextended LD flaps were employed.[35 ] We believe that close monitoring of drains, together with patient awareness of the
importance of careful wound care are essential aspects in reducing postoperative complications.
Length of FALD surgery hospital stay and reoperation due to complications have been
lower than data provided by studies evaluating microsurgical ABR.[36 ]
[37 ]
Conclusion
FALD is a total ABR technique with a low complication rate and very rare reconstructive
failure. This is particularly important for patients who have suffered previous reconstructive
failures.
The considerable volume of fat graft in a single surgery makes it possible to reconstruct
breasts of a reasonable size. Additional volume or small corrections in the shape
and contour of the reconstructed breast can easily be achieved with subsequent lipofilling.
Due to its efficiency, FALD technique must be considered an option to be taken into
account when an autologous, but safe and efficient reconstruction, is desired.
