Fat Transfer for Breast Reconstruction

Abstract

Sir: Fat grafting to the breast is an old concept. Czerny first described breast reconstruction by fat transfer in 1895.1 After a long and controversial history, fat grafting has become an invaluable tool in breast reconstruction. It is used for core reconstruction and as an ancillary technique after various procedures for breast reconstruction. Unfortunately, in many cases, the recipient area is deformed by previous oncologic surgery, radiotherapy, or other pathologic circumstances. To address this issue, we use the three-dimensional ligamentous band release technique, or “rigottomy.” This technique was first described by Gino Rigotti, who used a pickle fork to release heavily scarred, recipient-site–radiated tissue.2 Three-dimensional ligamentous band release followed by adipose tissue grafting can be used effectively in breast reconstructive surgery, breast augmentation, and for the treatment of Dupuytren contracture.3–5 Breast deformities due to internal ligamentous bands and extensive scars can be successfully treated percutaneously. Immediately before fat injections to the breast, an 18-gauge Tuohy needle is inserted into multiple sites to release parenchymal tethering and scars, thereby creating a matrix that is the scaffold that will better accept fat grafts. In fact, decreased interstitial pressure leads to increased tissue perfusion and more engraftment potential. At our institution, from September of 2011 to September of 2012, we performed 11 three-dimensional ligamentous band release procedures before fat grafting to the breast. Eight patients were treated after breast-conserving surgery and three patients after expander-implant breast reconstruction. The sequelae of breast-conserving surgery are a challenge for plastic surgeons. Fat grafting with the release of parenchymal tethering and constriction bands improves breast contour, which appears smoother and more harmonious after the procedure. Before fat injections, once adipose tissue has been harvested and purified, the skin of the breast is raised and placed under tension using two nylon stitches. Multiple breast puncture wounds are then made with a Tuohy epidural needle, and the constriction bands are progressively and extensively severed through slight transverse oscillations at each puncture point (Fig. 1). The 18-gauge Tuohy needle we use is 9 cm long and has a blunt bevel with a 30-degree curve at the tip. With its long and firm cannula, the Tuohy needle can be handled efficiently by the surgeon, allowing a stable hold. Tension is maintained by constantly stretching the skin of the breast using the nylon suture, as the ligamentous bands progressively give way. Frequently, it is necessary to replace the stitches during the procedure if the area to be addressed is wide. Residual parenchymal tethering and scars are localized by palpation and treated in the same fashion. We carefully avoid creating an empty space where the adipose-grafted tissue cannot be nourished. Otherwise, we mesh the ligamentous band in multiple levels and planes, converting the cicatrix into a three-dimensional matrix that subsequently will be filled by adipose tissue grafts. In our practice, we have found that percutaneous three-dimensional ligamentous band release is also very useful in expander-implant breast reconstruction, mostly for the treatment of acquired contour deformities due to cicatricial adhesions secondary to extensive postoperative scarring or radiotherapy. Constriction bands are broken up through slight transverse oscillations of a Tuohy needle under the scar, taking care not to damage the implant.Fig. 1: Three-dimensional ligamentous band release with a Tuohy needle, intraoperative view. Constriction bands are progressively severed in multiple planes through slight transverse oscillations at each puncture point.In conclusion, three-dimensional ligamentous band release with a Tuohy needle has dual beneficial effects: it allows the surgeon to break the constriction bands, and it increases parenchymal space, thereby reducing graft crowding and filling pressure. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.