UK Guidelines for Lipomodelling of the Breast on behalf of Plastic, Reconstructive and Aesthetic Surgery and Association of Breast Surgery Expert Advisory Group

Joanna Skillman; Penelope McManus; Pud Bhaskar; Stephen Hamilton; P.G. Roy; J.M. O'Donoghue

doi:10.1016/j.bjps.2021.09.033

Review| Volume 75, ISSUE 2, P511-518, February 2022

UK Guidelines for Lipomodelling of the Breast on behalf of Plastic, Reconstructive and Aesthetic Surgery and Association of Breast Surgery Expert Advisory Group

Joanna Skillman
Joanna Skillman
Correspondence
Corresponding author
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Affiliations
Consultant Plastic Surgeon, University Hospital Coventry and Warwickshire NHS Trust
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Penelope McManus
Penelope McManus
Affiliations
Consultant Oncoplastic Breast Surgeon, University Hospitals of Morecambe Bay NHS Foundation Trust
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Pud Bhaskar
Pud Bhaskar
Affiliations
Consultant Oncoplastic Breast Surgeon, North Tees and Hartlepool NHS Trust
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Stephen Hamilton
Stephen Hamilton
Affiliations
Consultant Plastic Surgeon, Royal Free London NHS Foundation Trust
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P.G. Roy
P.G. Roy
Affiliations
Consultant Oncoplastic Breast Surgeon, Oxford University Hospitals
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J.M. O'Donoghue
J.M. O'Donoghue
Affiliations
FRCS Plast Newcastle upon Tyne NHS Foundation Trust
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Open AccessPublished:October 18, 2021DOI:https://doi.org/10.1016/j.bjps.2021.09.033

Summary

Lipomodelling has become increasingly popular for reconstructive, aesthetic and therapeutic indications. The guidelines summarise available evidence for indications, training, technique, audit and outcomes in lipomodelling and also highlight areas for further research.

Keywords

Background

The injection of autologous fat into the breast has become popular over the last 20 years and its role has expanded to cover almost all aspects of reconstructive and aesthetic breast surgery. Following the description by Illouz in 1986

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of using fat grafts to fill depressions, Bircoll

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described cosmetic breast augmentation utilising autologous fat and liposuction techniques in 1987. After publications by Coleman

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demonstrating the efficacy of structural fat grafting to the face, the procedure for lipomodelling to the breast was popularised by Delay

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and others. Other terms used to describe the procedure are autologous fat transfer, fat grafting and lipomodelling.

AIMS

These guidelines aim to update the Joint Guidelines from the Association of Breast Surgery, the British Association of Plastic, Reconstructive and Aesthetic Surgeons, and the British Association of Aesthetic Plastic Surgeons published in 2012

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Joint Guidelines from the Association of Breast Surgery tBAoP, Reconstructive and Aesthetic Surgeons, and the British Association of Aesthetic Plastic Surgeons. Lipomodelling Guidelines for Breast Surgery 2012.

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and provide guidance on current indications, training and techniques, outcomes and areas for future research.

INDICATIONS

Indications for lipomodelling to the breast are wide and varied and it is not possible to draw up an exhaustive list. Predominantly, indications can be divided into those for breast reconstruction, aesthetic breast surgery and therapeutic purposes.

Post-mastectomy Reconstruction

1. Primary reconstruction

In conjunction with other methods of reconstruction.

Lipomodelling can be planned as part of a primary breast reconstruction and can be used in combination with free or pedicled flaps or with implants and tissue expanders

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as well as with serial tissue expansion in the subpectoral plane.

Concern over the number of procedures required to achieve satisfactory outcomes has led to increasing use of lipomodelling at the time of the primary reconstructive surgery. Some surgeons recommend lipomodelling of the mastectomy skin flaps and the pectoralis major muscle at the time of either implant or flap procedure and also into the latissimus dorsi flap itself, allowing greater volume transfer at the first operation and reducing the need for subsequent procedures.

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2. Total breast reconstruction

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using various devices prior to fat transfer, to improve graft uptake, but have not been widely adopted.

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has been reported to improve outcomes in high-risk patients not suitable for more complex surgery.

3. Irradiated chest wall.

Lipomodelling has been shown to improve the quality of irradiated tissues

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and can be utilised before or during reconstruction to enable implant-based reconstruction and reduce the risks of associated complications

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Secondary reconstruction

Lipomodelling is indicated for the improvement of volume and contours following reconstruction

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and the replacement of implant volume beneath flaps following implant removal due to complications

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Partial breast reconstruction

Lipomodelling has been shown to be oncologically safe for the correction of breast conservation defects

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though good results can be difficult to achieve following radiotherapy especially in the context of persistent fat necrosis. Immediate lipomodelling at the time of cancer surgery shows promising results and may reduce the incidence of post-operative deformity

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Breast asymmetry and developmental anomalies

Lipomodelling is indicated for the correction of hypoplastic breast syndrome and Poland's syndrome and may obviate the need for implants or flap transfer

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Aesthetic breast surgery

Lipomodelling alone can be used for cosmetic volume enhancement

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It can also be used in conjunction with mastopexy (immediate or delayed) to avoid using implants

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and following capsulectomy and removal of implants to improve the cosmetic result

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Lipomodelling is used with caution to correct donor site deformities after autologous flap harvest. After gluteal flap harvest, infiltration of fat should be subcutaneous to avoid injection into the gluteal muscle or deep veins, as there is a higher risk of fat embolism and death (www.surgery.org/sites/default/files/Gluteal-Fat-Grafting-02-06-18_0.pdf).

Therapeutic Indications

Lipomodelling can be useful in the management of capsular contracture, for enhancement of soft tissue coverage and amelioration of discomfort, either as sole treatment or in combination with capsulectomy and/or change of implants

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and for some patients may be an alternative to medication and its associated side effects.

Both clinical and in vitro studies

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have shown that fat transfer can be an effective therapy for radiotherapy tissue changes such as radiodermatitis, improving the quality of irradiated tissues and promoting wound healing. However, caution should be exercised in the presence of established radionecrosis, when a multidisciplinary approach is recommended.

PATIENT SELECTION

Patients must have suitable donor sites and be fit for surgery, potentially for multiple procedures.

Radiotherapy reduces fat graft survival, but although there is limited evidence on the impact of other patient factors, it appears that increasing age, body mass index, diabetes and tamoxifen may also affect outcomes

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TRAINING AND TECHNIQUE

Introduction

Fat transfer is often the technique of choice to correct volume or contour defects in reconstructive and cosmetic surgery. Considerable expertise is required to achieve optimal results in lipomodelling. Where clinicians and hospitals are introducing lipomodelling in their institution, they should follow local established clinical governance processes for implementing new procedures.

These guidelines aim to describe the standard technique for the procedure and recommendations for training.

Training in Lipomodelling

Formal training should be undertaken under the mentorship of a breast or plastic surgeon with experience in lipomodelling and should include the following components:

-
Background theory and knowledge including indications and complications
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Practical skills
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Arrangements for supervision, assistance and mentoring during local implementation
-
Evidence of completion of training to an acceptable standard before starting to perform lipomodelling
-
Processes in place for consent, audit of efficacy, safety and long-term data collection using the core dataset
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Technique

Lipomodelling involves the transfer of fat from one area of the body to another. Success is dependent on techniques used for harvesting, processing and grafting of the fat.

Harvesting

Donor site aesthetics should be considered to minimise morbidity and deformity, and potentially improve and enhance the donor areas. Consideration also needs to be given to preserving potential future autologous flap donor sites. It is essential that the surgeon is trained to assess, plan and deliver an aesthetically pleasing outcome (http:// www.bapras.org.uk/docs/default-source/default-document-library/bapras-baaps-lipo-suction-guidelines.pdf?sfvrsn=2). Fat donor sites should be accessible and consideration may be given to the likelihood of including adipose-derived stem cells (ADSC), which are reported to be higher in the inner knee and lower abdomen

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Infiltration of the donor area is not compulsory but facilitates analgesia and reduces bruising

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Stab incisions are made with an 11 blade for access. Infiltration can be undertaken first. A 2–4 mm blunt-tipped fat harvest cannula, preferably with a number of small holes near the tip is selected. Smaller fat particle size corresponds to better adipocyte survival, however, smaller cannula openings correspond to slower and more difficult fat graft harvesting with potential more cellular damage

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. Fat is harvested by passing the cannula back and forth through the fat in a fan pattern, avoiding over harvest in any particular location. A number of access incisions allow a more uniform harvest. Care should be taken to avoid superficial fat harvest to reduce the chance of skin irregularity or necrosis. Gentle suction can be applied by hand with a 10 ml Luer-lock syringe or with a low vacuum to avoid damage to the fat cells. Low-pressure suction (<250 mmHg) appears to increase adipocyte viability

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Processing

After aspiration of the fatty tissue, it is important that nonviable components of the aspirate such as oil, blood, and tumescence solution are removed and, at the same time, the quality, integrity, and viability of the adipocytes and the inherent mesenchymal stem cells in the aspirate are maintained. Processing techniques include sedimentation, filtration, washing and centrifugation. There is no consensus as to the optimal method of fat graft preparation

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The most evidence available is for centrifugation of the lipoaspirate at 3000rpm for 1–3 minutes to separate the fluid (decanted) and oil (absorbed) leaving fat cells

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Fat injection

Lipomodelling requires the grafted fat to be revascularised by the surrounding tissues. This is dependent on very small aliquots of undamaged fat cells being placed into a healthy recipient bed. In order to achieve these aims, small amounts of fat are injected with blunt-tipped small calibre infiltration cannulae (17–18G, maximum diameter 1.5mm), using a Luer-lock syringe. The cannula is pushed gently through the tissues that require grafting via a small stab incision and the fat is injected slowly as the cannula is withdrawn. It is recommended that about 1cc of fat is injected with each pass to achieve optimal deposition. A fresh tunnel is then created for the next pass. Tunnels are all separate from one another and are at different depths and angles to create a lattice of fat deposits. Multiple infiltration sites around the recipient area can facilitate uniform enhancement of the area. Care should be taken to avoid depositing larger volumes of fat in a single site, as the fat cells will fail to revascularise. This could cause oil cysts, microcalcification or fat necrosis, which may require subsequent imaging and biopsy.

Care should also be taken to avoid damage to adjacent structures, in particular breast implants or the pleura by injecting tangentially where possible. It is advisable to undertake injections prior to implant insertion or exchange during a combined procedure.

The recipient area capacity limits the amount of fat that can be injected in a single session, therefore, patients may require repeat procedures to achieve optimal results. The final volume achieved tends to remain stable in the long term, provided the patient maintains a constant weight and avoids smoking. Some surgeons recommend exceeding volume requirements to compensate for anticipated resorption,

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but only if the recipient area capacity is sufficient.

Preconditioning of recipient sites

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COMPLICATIONS

Complications in lipomodelling tend to be minor and well-tolerated and major complications are rare. Overall, 7% of patients develop a complication. Among these, 86% are reported as minor and do not need any therapeutic intervention

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Donor site

Complications include post-operative bruising and swelling, which can be reduced by using infiltration with adrenaline solution (1:100,000). Postoperative compression garments may help. Contour irregularity and skin necrosis can be avoided by good technique as described above.

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Recipient site

Fat necrosis is the most common complication; occurring in 3–15% of patients. It can lead to increased graft loss, oil cyst formation and calcifications

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. Once fat necrosis is established and has not resolved spontaneously, it may require formal aspiration or surgical excision.

Other complications are usually mild and self-limiting. Bruising is common, but haematoma and infection are rare. Perioperative antibiotics can be used according to local guidelines, particularly in the presence of breast implants. Postoperative infection increases the risk of graft loss. Medium-term complications can include hypertrophic scarring, contour irregularities, skin necrosis, over or under-correction.

The most serious complications, which are very rare, include damage to underlying structures, intravascular injection with fat embolism and death

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Fat resorption of 30–50% is not a complication and is expected after each procedure. Patients should be made aware that multiple procedures may be required.

ROLE OF IMAGING AFTER BREAST LIPOMODELLING

Breast cancer patients should continue clinical and mammographic follow-up by the multidisciplinary team (MDT) according to local protocols. In patients without a previous history of breast cancer, routine follow-up imaging is not advised, other than screening mammography through the National Health Service (NHS) Breast Screening Programme.

Patients who have undergone lipomodelling may present with symptomatic or screen-detected abnormalities in the breast

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Patients who have undergone lipomodelling are at increased risk of fat necrosis and subsequently more likely to have calcifications visible on mammography. Mammographic signs of fat necrosis may not be visible for at least 12–18 months. These calcifications have a typical appearance and are usually easily recognisable. However, patients need to be made aware, this may lead to an increase need for biopsy

⁶³

Carvajal J
Patiño JH.

Mammographic findings after breast augmentation with au- tologous fat injection.

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^,

⁶⁴

Cheung M
Houssami N
Lim E.

The unusual mammographic appearance of breasts augmented by autologous fat injection.

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, leading to additional radiological exposure and potential psychological anxiety.

ONCOLOGICAL SAFETY CONSIDERATIONS

There is no evidence that lipomodelling adversely affects breast cancer detection, surveillance or recurrence rates

⁶⁷

Agha RA
Fowler AJ
Herlin C
et al.

Use of autologous fat grafting for breast re- construction: a systematic review with meta-analysis of oncological outcomes.

Google Scholar

^,

⁶⁸

Krastev TK
Schop SJ
Hommes J
et al.

Meta-analysis of the oncological safety of autologous fat transfer after breast cancer.

Google Scholar

^,

⁶⁹

Spear SL
Wilson HB
Lockwood MD.

Fat injection to correct contour deformities in the reconstructed breast.

Google Scholar

^,

⁷⁰

Chan CW
McCulley SJ
Macmillan RD.

Autologous fat transfer–a review of the literature with a focus on breast cancer surgery.

Google Scholar

^,

⁷¹

Kanchwala SK
Glatt BS
Conant EF
et al.

Autologous fat grafting to the recon- structed breast: the management of acquired contour deformities.

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^,

⁷²

Breast reconstruction using lipomodelling after breast cancer treatment. NICE guidance, Jan 2012.

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. There is no evidence to suggest that fat injection into the breast parenchyma is unsafe. Long-term data are awaited for newer techniques, such as immediate lipomodelling at the time of cancer resection

²¹

Khan LR
Raine CR
Dixon JM.

Immediate lipofilling in breast conserving surgery.

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.

OUTCOMES AND AUDIT

A core outcome dataset

³⁷

Agha RA
Pidgeon TE
Borrelli MR
et al.

Validated Outcomes in the Grafting of Autologous Fat to the Breast: The VOGUE Study. Development of a Core Outcome Set for Research and Audit.

Google Scholar

(Table 1) has been developed for use in local and regional audit and research. Any unit undertaking lipomodelling should audit these core outcomes to ensure safety and efficacy.

Table 1Core Outcome Set

	Oncological Outcome
1	Rate of histologically confirmed locoregional cancer recurrence
	Clinical Outcome
2	All complications – including the actual number, percentage and the Clavien Dindo grading
	Aesthetic and Functional Outcomes
3	Surgeon assessment of volume, shape, symmetry, scarring and any improvement in skin trophicity/quality post-fat grafting (e.g. in irradiated breasts).
4	Ability to function and complete daily tasks, perform work and leisure related activities, ideally assessed using a validated instrument (e.g. EQ 5D, BREAST Q)
	Patient-reported outcomes
5	Overall patient-reported satisfaction with the appearance of their breast(s) after surgery ideally using a validated instrument (e.g. BREAST-Q)
6	Impact on quality of life such as self-esteem (feeling self-confident), emotional well-being (feelings of emotional and psychological health after surgery), normality (feeling ‘back to normal self’ of ‘whole’ as a results of surgery)
	Process Outcomes
7	How many fat grafting sessions needed to get optimal results as judged by the patient and/or surgeon (who made the judgement should be stated).
	Radiological Outcomes
8	The incidence of radiological abnormalities expressed quantitatively (e.g. as a number and a percentage)
9	Any interference with subsequent mammography scanning expressed quantitatively (e.g. as a number and percentage)

Open table in a new tab

Patient-reported outcomes

Pre- and post-operative photographs in additional to 3D imaging can be used to demonstrate outcomes and volume improvement objectively, which may be used as part of the patient record, for patient education to manage expectations and for medicolegal purposes. The majority of outcome studies indicate that patients were either satisfied or very satisfied after lipomodelling procedures

⁶⁷

Agha RA
Fowler AJ
Herlin C
et al.

Use of autologous fat grafting for breast re- construction: a systematic review with meta-analysis of oncological outcomes.

Google Scholar

.

Research

Topics for future research include strategies to improve graft survival

⁷³

Vyas KS
Vasconez HC
Morrison S
et al.

Fat Graft Enrichment Strategies: A Sys- tematic Review.

Google Scholar

, feasibility of fat banking

⁵⁴

Gal S
Pu LLQ.

An Update on Cryopreservation of Adipose Tissue.

Google Scholar

, the role of fat grafting in enhancing implant and autologous reconstruction, oncological safety of immediate lipomodelling after breast conserving surgery and in BRCA mutation carriers,. There is need for quality of life (QoL) studies after lipomodelling, as current evidence is limited

⁷⁴

Schop SJ
Joosen MEM
Wolswijk T
et al.

Quality of life after autologous fat transfer additional to prosthetic breast reconstruction in women after breast surgery: A systematic review.

Google Scholar

.

Declaration of Competing Interest

None

Author contributions

All Authors contributed to the literature review, writing, review and editing. All authors approved the final document.

Funding

None

Ethical Approval

N/A

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Article info

Publication history

Published online: October 18, 2021

Accepted: September 19, 2021

Received: March 29, 2021

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DOI: https://doi.org/10.1016/j.bjps.2021.09.033

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UK Guidelines for Lipomodelling of the Breast on behalf of Plastic, Reconstructive and Aesthetic Surgery and Association of Breast Surgery Expert Advisory Group

Summary

Keywords

Background

AIMS

INDICATIONS

Post-mastectomy Reconstruction

Secondary reconstruction

Partial breast reconstruction

Breast asymmetry and developmental anomalies

Aesthetic breast surgery

Therapeutic Indications

PATIENT SELECTION

TRAINING AND TECHNIQUE

Introduction

Training in Lipomodelling

Technique

Harvesting

Processing

Fat injection

Preconditioning of recipient sites

COMPLICATIONS

Donor site

Recipient site

ROLE OF IMAGING AFTER BREAST LIPOMODELLING

ONCOLOGICAL SAFETY CONSIDERATIONS

OUTCOMES AND AUDIT

Patient-reported outcomes

Research

Declaration of Competing Interest

Author contributions

Funding

Ethical Approval

References

Article info

Publication history

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Copyright

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For non-commercial purposes:

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