- Email: [email protected]
Early experience of immediate reconstruction using autologous free dermal fat graft after breast conservational surgery
Journal of Plastic, Reconstructive & Aesthetic Surgery (2007) 60, 495e502
Early experience of immediate reconstruction using autologous free dermal fat graft after breast conservational surgery Yuko Kijima*, Heiji Yoshinaka, Tetsuhiro Owaki, Takashi Aikou Department of Surgical Oncology, Breast and Endocrine Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan Received 27 March 2006; accepted 16 June 2006
KEYWORDS Breast cancer; Breast conservational surgery; Immediate reconstruction; Autologous; Free dermal fat graft
Summary Breast conservational therapy (BCT) has become a standard strategy for breast cancer, and ensures that local control with acceptable cosmetic results [Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456e61] and immediate reconstruction after BCT has become increasingly popular even for early-stage breast cancer [Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79(4):567e72; Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869e73]. The breasts of Japanese women are sometimes too small to maintain symmetry, even after partial resection, and an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Use of an autologous free dermal fat graft (FDFG) for defect reconstruction has proven popular for some areas of the body [Lexer E. Free transplantation. Ann Surg 1914;60:166e94; Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233e50]. Immediate reconstruction of the surgical defect was performed in seven Japanese women using autologous free dermal fat graft (FDFG) from the lower abdomen after breastconserving surgeries for six malignant lesions and two benign masses located in the medial or central area of the breasts. The mean amount of resected tissue was 56.4 g (range, 28e108 g), while mean FDFG weight was 78.3 g (range, 35e148 g). We obtained symmetry in the size of the whole breast, the position and level of the nipple, and shape.
* Corresponding author. Tel.: þ81 99 275 5361; fax: þ81 99 265 7426. E-mail address: [email protected] (Y. Kijima). 1748-6815/$-seefrontmatterª2006British Associationof Plastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved. doi:10.1016/j.bjps.2006.06.004
496
Y. Kijima et al. Autologous FDFG was useful for reconstruction, with a good cosmetic effect. This technique achieves better cosmetic results than the transposition of residual breast tissue, is more convenient than muscle flap grafting, and safer than implantation of foreign materials. This report documents our early experiences with seven patients who underwent BCT and immediate breast reconstruction using autologous FDFG. ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Material and methods Patients Immediate reconstruction of surgical defects was performed in seven Japanese women using autologous free dermal fat graft (FDFG) after breastconserving surgeries for six malignant lesions and two benign masses in the Department of Breast and Endocrine Surgery at Kagoshima University, Kagoshima, Japan from October 2003 to December 2004. Mean patient age was 49.8 years (range, 37e70 years). In five patients, lesions were diagnosed as breast cancer by fine needle aspiration and one patient was diagnosed with invasive ductal carcinoma by excisional biopsy. In the remaining patient, two lesions were diagnosed as intraductal papilloma. Out of eight lesions, one lesion was on lateral, one was on central and the other six were on medially area (Table 1). Informed consent was obtained preoperatively after explaining the following: (1) the trial involved a new procedure aiming at improving the cosmetic results of the treatment or inner or central lesions; (2) there would be an extra scar on the lower abdomen, at the donor site for autologous FDFG; (3) operative duration may be much longer than breast-conserving surgery without reconstruction; and (4) cosmetic results may be adversely affected if a histologically positive surgical margin requires adjuvant radiotherapy. The mean follow-up period was 23.3 months (range, 15e29 months).
papilloma underwent wide excision with a margin of 1 cm, without axillary lymph node dissection. Surgical margins and SLNs were examined histologically during the operation and a lack of involvement was confirmed. Meticulous haemostasis of the surface of the pectoralis major muscle was achieved. Harvesting FDFG To accurately estimate FDFG size, the surgical margin was marked and the estimated breast defect was measured preoperatively with the patient standing (Figs. 1a, 2a, and 3a). FDFG was harvested using a low transverse incision that allows the donor scar to be hidden beneath the bikini line. In situ de-epithelialization of the entire skin paddle was achieved using a knife. An ellipse of fat and dermis was removed by sharp dissection (Figs. 4a, b). In this series, unavoidable volume loss following implantation was offset by leaving the graft 25e30% thicker than ultimately desired (Table 1). The graft’s length and breadth matched the defect because the dermal component resists condition when sutured securely along the periphery.
Operation procedures
Trimming of FDFG Autologous FDFG was trimmed to remove excess fat and allow tissue to be transferred into the breast deformity. The FDFG was made thinner to replace the upper portion of the breast, and thicker to replace the area under the nipple and areola, so that cosmetic reconstruction resulted in a more natural final appearance.
Tumour resection In the six patients with malignant lesions, the tumour was removed with a surgical margin of 2e4 cm and included the underlying pectoral fascia. Sentinel lymph node (SLN) biopsy was performed in three patients, and axillary dissection in another three patients. The patient with bilateral lesions preoperatively diagnosed as intraductal
Implantation and dressing After tailoring to conform to the defect, the FDFG was turned over so that the dermis faced the surface of the pectoralis major and revascularization could occur between these two surfaces. FDFG was fixed securely along the entire periphery using multiple deep 4/0 PDS sutures (Fig. 4c). The procedure was completed using a careful
37 Left (upper inner) 21
25 IDCb 10 7 110 118
46 Right (upper inner) 15
18 IDCb 76 69 65
47 Left (upper inner) 9
12 IDCb 12 7 108 148
two-layer skin closure with deep 4/0 PDS sutures and 5/0 Nylon running sutures. An open drain to the surface of the FDFG and closed suction drainage of the donor site were applied. After suturing the incision at the graft site, a supporting dressing was applied firmly but not tightly over the graft and left in place for 2 days. Postoperative care was as per usual. Closure of donor site The donor site was closed using multiple interrupted 3/0 PDS sutures placed through the adipose and subcutaneous tissues, while 5/0 PDS sutures were used to close the dermis. All surgical margins were histologically cancer free postoperatively and no patients received radiotherapy on the ipsilateral breast.
11 IDCb 87 50 80 14 Papilloma 55 28 35
c
a
b
Histological margins are shown. Invasive ductal carcinoma. The length of resected area was designed and marked standing.
10 Papilloma 44 33 50 23 IDCb 98 50 70
Histological size of invasive lesion (mm) Excisional margina (mm) Histology Resected areac (cm) Resected amount (g) Grafted amount (g)
7 IDCb 77 45 60
61 Left (central) 3 61 Left (upper inner) 9 38 Right (lower inner) 7 Age Location (area)
2 1 Patients profile Table 1
497
Results
Case
3
Right (centrallower outer) 9
70 Left (upper inner) 5
7 5 4
6
Immediate reconstruction using autologous free dermal fat graft
Table 1 shows the demographic data of the patients. In six patients diagnosed with invasive ductal carcinoma, the mean histological tumour diameter was 13.2 mm. Case 3 had bilateral lesions, which were diagnosed as benign tumours in the central region of each breast. The mean amount of resected tissue was 56.4 g (range, 28e108 g), while the mean FDFG weight was 78.3 g (range, 35e148 g). As Case 3 underwent simultaneous wedge resection of the lung for concomitant lung carcinoma, correct data for tumour resection and immediate reconstruction of bilateral breasts were unknown. For the remaining patients, the mean total operative duration was 196 min (range, 165e225 min), mean duration of the reconstructive process was 82 min (range, 50e105 min), and mean blood loss for BCT and immediate breast reconstruction was 165 g (range, 90e340 g). In all patients, the open drain was left in place until postoperative day 3, and the closed suction tube until day 2. All patients were satisfied with their new breast, except for one case. We observed good symmetry in the size of the whole breast, the position and level of the nipple, and shape, although deformity remained in patients who had undergone axillary lymph node dissection. We could easily identify the harvested FDFG after surgery using ultrasonography (Fig. 5). The harvested and living FDFG was revealed as a solid mass with an internal echo level lower than the adjacent normal gland and subcutaneous fatty tissue with no cystic degeneration. We have not observed any absorption of these eight grafts or deformation of the reconstructed breasts.
498
Y. Kijima et al.
Figure 1
(a) Tumour excised with a 1 cm margin. (b) Twelve months postoperatively (Case 3).
Discussion In the 1980s, BCT rapidly became a first-line procedure for early-stage breast cancer, and ensured local control and acceptable cosmetic results.1,2 Insufficient resection margins as a result of paying too much attention to cosmesis may increase local recurrence, and determining the amount of breast tissue that must be removed to obtain histologically negative margins is difficult. Early research suggested that conservation or restitution of the breast might mitigate the negative effects of breast cancer on the sexual well-being of women, and cosmetic results exert a marked effect on subsequent psychological outcomes.3,4 Japanese women typically have small breasts, and symmetry can be difficult when a tumour is located in the inner region of the breast, even with only partial resection. Removing a large part of the breast can thus have considerable impact on the cosmetic outcome. BCT thus cannot always provide satisfactory cosmetic results in patients with small breasts. Local control and good cosmetic results represent the primary goals of every BCT for breast cancer. Deformity following breast-conserving surgery depends on the area of skin excised, the volume of subcutaneous and glandular tissue resected, development of postoperative fibrosis, scar contracture, and the effects of radio and chemotherapy.5 Mild deformation can be corrected using minor procedures such as transposition
of local flaps, wide undermining, and conization of the residual breast tissue.6,7 Wide local excision without immediate volume replacement is associated with breast retraction leading to cosmetic failure in one-third of patients.8 These severe defects require immediate or delayed transposition of suitable tissue or implants. Using latissimus dorsi muscle transposition, one of the most popular methods, sufficient breast tissue resection for tumour-free margins can be achieved, with subsequent breast tissue deficiency immediately repaired using transposition.5 Raja et al.8 reported that immediate volume replacement with latissimus dorsi muscle flap can avoid many of the cosmetic issues associated with extensive local resection. However, this technique is better suited to patients with laterally located tumours, and requires complete sacrifice of a large muscle that represents an adequate donor for reconstructive surgery after total mastectomy if the patient requires further treatment due to positive margins after initial BCT. Autologous FDFG has been used sporadically for soft tissue augmentation in the past9,10. Bames in 1953 and Watson in 1959 reported the use of dermal-fat transplants from the buttocks to recontour small breasts.11,12 Numerous authors have reported positive clinical results with FDFG reconstruction of facial contour defects. The risk of unexpected FDFG resorption represents a far greater threat to satisfactory long-term outcomes. Although the fate of implanted FDFG adipose tissue is uncertain, even ideal patients display some
Immediate reconstruction using autologous free dermal fat graft
Figure 2 (Case 6).
499
(a) Upper inner quadrant lesion excised with a 2 cm margin. (bed) Eighteen months postoperatively
degree of permanent FDFG volume loss within several weeks after implantation.13e16 Mackay et al. reported that in dermis grafts implanted in animal models, adipose tissue tended to disappear, a significant part being replaced by fibrous tissue. Experimental evidence suggests that FDFG adipose tissue is at least partially replaced by host fibrous tissue, but the texture and pliability of the graft are clinically preserved for years after implantation.17 Several factors may account for variations in the loss of implanted graft volume, including
fat resorption from extensive graft thickness, traumatic graft handling, haematoma, wound infection, inadequate immobilization, or poor vascularity of implanted tissue.18,19 While the precise sequence of FDFG revascularization is uncertain, inclusion of the attached dermis to the transplanted fat seems to enhance fat survival. Given the inevitable volume loss of implanted FDFG, many authors have recommended initial overcorrection of 10e40%.19,20 FDFGs have been found to show predictable resorption by 25e30%
500
Y. Kijima et al.
Figure 3 (a) Upper inner quadrant lesion excised with a 2.5e4 cm margin. (bed) Twelve months postoperatively (Case 7). The level and position of the nipple were excellent.
when subdermal fat is limited to thicknesses of 1.5 cm. We preoperatively estimated the glandular defect following BCT, and designed and harvested FDFG with thickness limitations in mind. FDFGs were trimmed intraoperatively for suitable replacement of each defect, and the subsequent volume of each FDFG was about 130% of the resected volume. We can easily confirm the harvested FDFG from the point of size, volume, and necrosis using ultrasonography. Furthermore, examinations using ultrasonography and mammography convinced us that this new harvest does not obscure views of new lesions of the remnant gland.
One drawback of our technique is the extra scar on the lower abdomen at the donor site. However, contrary to our expectations, no patients complained about this extra scar, and were satisfied with their new body image due to a reduced volume of extra fatty tissue in the abdomen. To evaluate immediate breast reconstruction with FDFG, a larger patient cohort should be studied for a longer period. However, FDFG provides a lasting, reliable and effective source of autologous implant material for the repair of breast contour defects when used appropriately in selected patients.
Immediate reconstruction using autologous free dermal fat graft
501
Figure 4 (a) In situ de-epithelialization of the entire skin paddle was performed. (b) An ellipse of fat and dermis was removed by sharp dissection. (c) The FDFG was turned over so that the dermis faced the surface of the pectoralis major and was fixed securely along the entire periphery.
In conclusion, this technique provides better cosmetic results than transposition of residual breast tissue, is more convenient than muscle flap grafting and is safer than using foreign implants. Immediate volume replacement using autologous FDFG at the time of BCT on the inner or central region can be useful for defect reconstruction with good cosmetic effect, particularly for patients with small breasts, such as Japanese women.
Figure 5 Ultrasonography revealed good FDFG volume one year after the operation (F: FDFG, G: normal gland).
References 1. Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456e61. 2. Fisher B, Anderson SA, Bryant J, et al. Twenty-year followup of a randomized trial comparing total mastectomy, lumpectomy, an lumpectomy plus irradiation for the treatment of invasive breast cancer. N Engl J Med 2002;347: 1233e41. 3. Rowland JH, Desmond KA, Meyerowitz BE, et al. Role of breast reconstructive surgery in physical and emotional outcomes among breast cancer survivors. J Natl Cancer Inst 2000;92:1422e9. 4. Al-Ghazal SK, Fallowfield L, Blamey RW. Does cosmetic outcome from treatment of primary breast cancer influence psychosocial morbidity? Eur J Surg Oncol 1999;25:571e3. 5. Noguchi M, Taniya T, Miyazaki I, et al. Immediate transposition of a latissimus dorsi muscle for correcting a postquadrantectomy breast deformity in Japanese patients. Int Surg 1990;75:166e70. 6. Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79(4):567e72. 7. Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869e73. 8. Raja MAK, Straker VF, Rainsbyry RM. Extending the role of breast-conserving surgery by immediate volume replacement. Br J Surg 1997;84:101e5. 9. Lexer E. Free transplantation. Ann Surg 1914;60:166e94. 10. Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233e50.
502 11. Bames HO. Augmentation mammoplasty by lipo-transplant. Plast Reconstr Surg 1953;11:404e13. 12. Watson J. Some observation on free fat grafts: with reference to their use in mammoplasty. Br J Plast Surg 1959;12:263e74. 13. Thompson N. The subcutaneous dermis graft. Plast Reconstr Surg 1960;26:1e22. 14. Boering G, Hurrstadt AJC. The use of derma-fat grafts in the face. Br J Plast Surg 1967;20:172e8. 15. Leaf N, Zarem HA. Correction of contour defects of the face with dermal and dermal-fat grafts. Arch Surg 1972;105: 715e9.
Y. Kijima et al. 16. Davis Richard E, Guida Robert A, Cook Ted A. Autologous free dermal fat graft reconstruction of facial contour defects. Arch Otolaryngol Head Neck Surg 1995;121:95e100. 17. Mackay DR, Manders EK, Saggers GC, et al. The fate of dermal and dermal-fat grafts. Ann Plast Surg 1993;31:42e6. 18. Conley JJ, Clairmont AA. Dermal-fat-fascia grafts. Otolaryngology 1978;86:641e9. 19. Nosan DK, Ochi JW, Dabvidson TM. Preservation of facial contour during parotidectomy. Otolarygol Head Neck Surg 1991;104:293e8. 20. Guyrwitz PJ, Sarel R. Facial reconstruction in partial lipodystrophy. Ann Plast Surg 1982;8:253e7.
Early experience of immediate reconstruction using autologous free dermal fat graft after breast conservational surgery Yuko Kijima*, Heiji Yoshinaka, Tetsuhiro Owaki, Takashi Aikou Department of Surgical Oncology, Breast and Endocrine Surgery, Kagoshima University Graduate School of Medical and Dental Sciences, 8-35-1 Sakuragaoka, Kagoshima 890-8520, Japan Received 27 March 2006; accepted 16 June 2006
KEYWORDS Breast cancer; Breast conservational surgery; Immediate reconstruction; Autologous; Free dermal fat graft
Summary Breast conservational therapy (BCT) has become a standard strategy for breast cancer, and ensures that local control with acceptable cosmetic results [Fisher B, Anderson S, Redmond CK, et al. Reanalysis and results after 12 years of follow-up in a randomized clinical trial comparing total mastectomy with lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1995;333:1456e61] and immediate reconstruction after BCT has become increasingly popular even for early-stage breast cancer [Berrino P, Campora E, Santi P. Post-quadrantectomy breast deformities: classification and techniques of surgical correction. Plast Reconstr Surg 1987;79(4):567e72; Cooperman AM, Dinner M. The rhomboid flap and partial mastectomy. Surg Clin North Am 1978;58:869e73]. The breasts of Japanese women are sometimes too small to maintain symmetry, even after partial resection, and an insufficient resection margin may increase local recurrence if too much attention is paid to cosmesis. Use of an autologous free dermal fat graft (FDFG) for defect reconstruction has proven popular for some areas of the body [Lexer E. Free transplantation. Ann Surg 1914;60:166e94; Peer LA. The neglected free fat graft. Plast Reconstr Surg 1956;18:233e50]. Immediate reconstruction of the surgical defect was performed in seven Japanese women using autologous free dermal fat graft (FDFG) from the lower abdomen after breastconserving surgeries for six malignant lesions and two benign masses located in the medial or central area of the breasts. The mean amount of resected tissue was 56.4 g (range, 28e108 g), while mean FDFG weight was 78.3 g (range, 35e148 g). We obtained symmetry in the size of the whole breast, the position and level of the nipple, and shape.
* Corresponding author. Tel.: þ81 99 275 5361; fax: þ81 99 265 7426. E-mail address: [email protected] (Y. Kijima). 1748-6815/$-seefrontmatterª2006British Associationof Plastic,ReconstructiveandAestheticSurgeons.PublishedbyElsevierLtd.All rightsreserved. doi:10.1016/j.bjps.2006.06.004
496
Y. Kijima et al. Autologous FDFG was useful for reconstruction, with a good cosmetic effect. This technique achieves better cosmetic results than the transposition of residual breast tissue, is more convenient than muscle flap grafting, and safer than implantation of foreign materials. This report documents our early experiences with seven patients who underwent BCT and immediate breast reconstruction using autologous FDFG. ª 2006 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
Material and methods Patients Immediate reconstruction of surgical defects was performed in seven Japanese women using autologous free dermal fat graft (FDFG) after breastconserving surgeries for six malignant lesions and two benign masses in the Department of Breast and Endocrine Surgery at Kagoshima University, Kagoshima, Japan from October 2003 to December 2004. Mean patient age was 49.8 years (range, 37e70 years). In five patients, lesions were diagnosed as breast cancer by fine needle aspiration and one patient was diagnosed with invasive ductal carcinoma by excisional biopsy. In the remaining patient, two lesions were diagnosed as intraductal papilloma. Out of eight lesions, one lesion was on lateral, one was on central and the other six were on medially area (Table 1). Informed consent was obtained preoperatively after explaining the following: (1) the trial involved a new procedure aiming at improving the cosmetic results of the treatment or inner or central lesions; (2) there would be an extra scar on the lower abdomen, at the donor site for autologous FDFG; (3) operative duration may be much longer than breast-conserving surgery without reconstruction; and (4) cosmetic results may be adversely affected if a histologically positive surgical margin requires adjuvant radiotherapy. The mean follow-up period was 23.3 months (range, 15e29 months).
papilloma underwent wide excision with a margin of 1 cm, without axillary lymph node dissection. Surgical margins and SLNs were examined histologically during the operation and a lack of involvement was confirmed. Meticulous haemostasis of the surface of the pectoralis major muscle was achieved. Harvesting FDFG To accurately estimate FDFG size, the surgical margin was marked and the estimated breast defect was measured preoperatively with the patient standing (Figs. 1a, 2a, and 3a). FDFG was harvested using a low transverse incision that allows the donor scar to be hidden beneath the bikini line. In situ de-epithelialization of the entire skin paddle was achieved using a knife. An ellipse of fat and dermis was removed by sharp dissection (Figs. 4a, b). In this series, unavoidable volume loss following implantation was offset by leaving the graft 25e30% thicker than ultimately desired (Table 1). The graft’s length and breadth matched the defect because the dermal component resists condition when sutured securely along the periphery.
Operation procedures
Trimming of FDFG Autologous FDFG was trimmed to remove excess fat and allow tissue to be transferred into the breast deformity. The FDFG was made thinner to replace the upper portion of the breast, and thicker to replace the area under the nipple and areola, so that cosmetic reconstruction resulted in a more natural final appearance.
Tumour resection In the six patients with malignant lesions, the tumour was removed with a surgical margin of 2e4 cm and included the underlying pectoral fascia. Sentinel lymph node (SLN) biopsy was performed in three patients, and axillary dissection in another three patients. The patient with bilateral lesions preoperatively diagnosed as intraductal
Implantation and dressing After tailoring to conform to the defect, the FDFG was turned over so that the dermis faced the surface of the pectoralis major and revascularization could occur between these two surfaces. FDFG was fixed securely along the entire periphery using multiple deep 4/0 PDS sutures (Fig. 4c). The procedure was completed using a careful
37 Left (upper inner) 21
25 IDCb 10 7 110 118
46 Right (upper inner) 15
18 IDCb 76 69 65
47 Left (upper inner) 9
12 IDCb 12 7 108 148
two-layer skin closure with deep 4/0 PDS sutures and 5/0 Nylon running sutures. An open drain to the surface of the FDFG and closed suction drainage of the donor site were applied. After suturing the incision at the graft site, a supporting dressing was applied firmly but not tightly over the graft and left in place for 2 days. Postoperative care was as per usual. Closure of donor site The donor site was closed using multiple interrupted 3/0 PDS sutures placed through the adipose and subcutaneous tissues, while 5/0 PDS sutures were used to close the dermis. All surgical margins were histologically cancer free postoperatively and no patients received radiotherapy on the ipsilateral breast.
11 IDCb 87 50 80 14 Papilloma 55 28 35
c
a
b
Histological margins are shown. Invasive ductal carcinoma. The length of resected area was designed and marked standing.
10 Papilloma 44 33 50 23 IDCb 98 50 70
Histological size of invasive lesion (mm) Excisional margina (mm) Histology Resected areac (cm) Resected amount (g) Grafted amount (g)
7 IDCb 77 45 60
61 Left (central) 3 61 Left (upper inner) 9 38 Right (lower inner) 7 Age Location (area)
2 1 Patients profile Table 1
497
Results
Case
3
Right (centrallower outer) 9
70 Left (upper inner) 5
7 5 4
6
Immediate reconstruction using autologous free dermal fat graft
Table 1 shows the demographic data of the patients. In six patients diagnosed with invasive ductal carcinoma, the mean histological tumour diameter was 13.2 mm. Case 3 had bilateral lesions, which were diagnosed as benign tumours in the central region of each breast. The mean amount of resected tissue was 56.4 g (range, 28e108 g), while the mean FDFG weight was 78.3 g (range, 35e148 g). As Case 3 underwent simultaneous wedge resection of the lung for concomitant lung carcinoma, correct data for tumour resection and immediate reconstruction of bilateral breasts were unknown. For the remaining patients, the mean total operative duration was 196 min (range, 165e225 min), mean duration of the reconstructive process was 82 min (range, 50e105 min), and mean blood loss for BCT and immediate breast reconstruction was 165 g (range, 90e340 g). In all patients, the open drain was left in place until postoperative day 3, and the closed suction tube until day 2. All patients were satisfied with their new breast, except for one case. We observed good symmetry in the size of the whole breast, the position and level of the nipple, and shape, although deformity remained in patients who had undergone axillary lymph node dissection. We could easily identify the harvested FDFG after surgery using ultrasonography (Fig. 5). The harvested and living FDFG was revealed as a solid mass with an internal echo level lower than the adjacent normal gland and subcutaneous fatty tissue with no cystic degeneration. We have not observed any absorption of these eight grafts or deformation of the reconstructed breasts.
498
Y. Kijima et al.
Figure 1
(a) Tumour excised with a 1 cm margin. (b) Twelve months postoperatively (Case 3).
Discussion In the 1980s, BCT rapidly became a first-line procedure for early-stage breast cancer, and ensured local control and acceptable cosmetic results.1,2 Insufficient resection margins as a result of paying too much attention to cosmesis may increase local recurrence, and determining the amount of breast tissue that must be removed to obtain histologically negative margins is difficult. Early research suggested that conservation or restitution of the breast might mitigate the negative effects of breast cancer on the sexual well-being of women, and cosmetic results exert a marked effect on subsequent psychological outcomes.3,4 Japanese women typically have small breasts, and symmetry can be difficult when a tumour is located in the inner region of the breast, even with only partial resection. Removing a large part of the breast can thus have considerable impact on the cosmetic outcome. BCT thus cannot always provide satisfactory cosmetic results in patients with small breasts. Local control and good cosmetic results represent the primary goals of every BCT for breast cancer. Deformity following breast-conserving surgery depends on the area of skin excised, the volume of subcutaneous and glandular tissue resected, development of postoperative fibrosis, scar contracture, and the effects of radio and chemotherapy.5 Mild deformation can be corrected using minor procedures such as transposition
of local flaps, wide undermining, and conization of the residual breast tissue.6,7 Wide local excision without immediate volume replacement is associated with breast retraction leading to cosmetic failure in one-third of patients.8 These severe defects require immediate or delayed transposition of suitable tissue or implants. Using latissimus dorsi muscle transposition, one of the most popular methods, sufficient breast tissue resection for tumour-free margins can be achieved, with subsequent breast tissue deficiency immediately repaired using transposition.5 Raja et al.8 reported that immediate volume replacement with latissimus dorsi muscle flap can avoid many of the cosmetic issues associated with extensive local resection. However, this technique is better suited to patients with laterally located tumours, and requires complete sacrifice of a large muscle that represents an adequate donor for reconstructive surgery after total mastectomy if the patient requires further treatment due to positive margins after initial BCT. Autologous FDFG has been used sporadically for soft tissue augmentation in the past9,10. Bames in 1953 and Watson in 1959 reported the use of dermal-fat transplants from the buttocks to recontour small breasts.11,12 Numerous authors have reported positive clinical results with FDFG reconstruction of facial contour defects. The risk of unexpected FDFG resorption represents a far greater threat to satisfactory long-term outcomes. Although the fate of implanted FDFG adipose tissue is uncertain, even ideal patients display some
Immediate reconstruction using autologous free dermal fat graft
Figure 2 (Case 6).
499
(a) Upper inner quadrant lesion excised with a 2 cm margin. (bed) Eighteen months postoperatively
degree of permanent FDFG volume loss within several weeks after implantation.13e16 Mackay et al. reported that in dermis grafts implanted in animal models, adipose tissue tended to disappear, a significant part being replaced by fibrous tissue. Experimental evidence suggests that FDFG adipose tissue is at least partially replaced by host fibrous tissue, but the texture and pliability of the graft are clinically preserved for years after implantation.17 Several factors may account for variations in the loss of implanted graft volume, including
fat resorption from extensive graft thickness, traumatic graft handling, haematoma, wound infection, inadequate immobilization, or poor vascularity of implanted tissue.18,19 While the precise sequence of FDFG revascularization is uncertain, inclusion of the attached dermis to the transplanted fat seems to enhance fat survival. Given the inevitable volume loss of implanted FDFG, many authors have recommended initial overcorrection of 10e40%.19,20 FDFGs have been found to show predictable resorption by 25e30%
500
Y. Kijima et al.
Figure 3 (a) Upper inner quadrant lesion excised with a 2.5e4 cm margin. (bed) Twelve months postoperatively (Case 7). The level and position of the nipple were excellent.
when subdermal fat is limited to thicknesses of 1.5 cm. We preoperatively estimated the glandular defect following BCT, and designed and harvested FDFG with thickness limitations in mind. FDFGs were trimmed intraoperatively for suitable replacement of each defect, and the subsequent volume of each FDFG was about 130% of the resected volume. We can easily confirm the harvested FDFG from the point of size, volume, and necrosis using ultrasonography. Furthermore, examinations using ultrasonography and mammography convinced us that this new harvest does not obscure views of new lesions of the remnant gland.
One drawback of our technique is the extra scar on the lower abdomen at the donor site. However, contrary to our expectations, no patients complained about this extra scar, and were satisfied with their new body image due to a reduced volume of extra fatty tissue in the abdomen. To evaluate immediate breast reconstruction with FDFG, a larger patient cohort should be studied for a longer period. However, FDFG provides a lasting, reliable and effective source of autologous implant material for the repair of breast contour defects when used appropriately in selected patients.
Immediate reconstruction using autologous free dermal fat graft
501
Figure 4 (a) In situ de-epithelialization of the entire skin paddle was performed. (b) An ellipse of fat and dermis was removed by sharp dissection. (c) The FDFG was turned over so that the dermis faced the surface of the pectoralis major and was fixed securely along the entire periphery.
In conclusion, this technique provides better cosmetic results than transposition of residual breast tissue, is more convenient than muscle flap grafting and is safer than using foreign implants. Immediate volume replacement using autologous FDFG at the time of BCT on the inner or central region can be useful for defect reconstruction with good cosmetic effect, particularly for patients with small breasts, such as Japanese women.
Figure 5 Ultrasonography revealed good FDFG volume one year after the operation (F: FDFG, G: normal gland).
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