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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Fat Grafting to the Breast, a Simple Procedure for a Very Complex Reconstruction</title><author><name sortKey="Claro, Francisco" sort="Claro, Francisco" uniqKey="Claro F" first="Francisco" last="Claro">Francisco Claro</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Pereira, Fernando Linhares" sort="Pereira, Fernando Linhares" uniqKey="Pereira F" first="Fernando Linhares" last="Pereira">Fernando Linhares Pereira</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Pinto Neto, Aarao M" sort="Pinto Neto, Aarao M" uniqKey="Pinto Neto A" first="Aarão M." last="Pinto-Neto">Aarão M. Pinto-Neto</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">27104093</idno><idno type="pmc">4801102</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4801102</idno><idno type="RBID">PMC:4801102</idno><idno type="doi">10.1097/GOX.0000000000000580</idno><date when="2016">2016</date><idno type="wicri:Area/Pmc/Corpus">000602</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000602</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Fat Grafting to the Breast, a Simple Procedure for a Very Complex Reconstruction</title><author><name sortKey="Claro, Francisco" sort="Claro, Francisco" uniqKey="Claro F" first="Francisco" last="Claro">Francisco Claro</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Pereira, Fernando Linhares" sort="Pereira, Fernando Linhares" uniqKey="Pereira F" first="Fernando Linhares" last="Pereira">Fernando Linhares Pereira</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author><author><name sortKey="Pinto Neto, Aarao M" sort="Pinto Neto, Aarao M" uniqKey="Pinto Neto A" first="Aarão M." last="Pinto-Neto">Aarão M. Pinto-Neto</name><affiliation><nlm:aff id="aff1"></nlm:aff></affiliation></author></analytic><series><title level="j">Plastic and Reconstructive Surgery Global Open</title><idno type="eISSN">2169-7574</idno><imprint><date when="2016">2016</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>Supplemental Digital Content is available in the text.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Claro, F" uniqKey="Claro F">F Claro</name></author><author><name sortKey="Figueiredo, Jc" uniqKey="Figueiredo J">JC Figueiredo</name></author><author><name sortKey="Zampar, Ag" uniqKey="Zampar A">AG Zampar</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Claro, F" uniqKey="Claro F">F Claro</name></author><author><name sortKey="Sarian, Lo" uniqKey="Sarian L">LO Sarian</name></author><author><name sortKey="Pinto Neto, Am" uniqKey="Pinto Neto A">AM Pinto-Neto</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="De Figueiredo, Jc" uniqKey="De Figueiredo J">JC de Figueiredo</name></author><author><name sortKey="Naufal, Rr" uniqKey="Naufal R">RR Naufal</name></author><author><name sortKey="Claro De Oliveira, F" uniqKey="Claro De Oliveira F">F Claro de Oliveira</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Goldsmith, Hs" uniqKey="Goldsmith H">HS Goldsmith</name></author><author><name sortKey="De Los Santos, R" uniqKey="De Los Santos R">R De los Santos</name></author><author><name sortKey="Beattie, Ej" uniqKey="Beattie E">EJ Beattie</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Goldhirsch, A" uniqKey="Goldhirsch A">A Goldhirsch</name></author><author><name sortKey="Winer, Ep" uniqKey="Winer E">EP Winer</name></author><author><name sortKey="Coates, As" uniqKey="Coates A">AS Coates</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Gutowski, Ka" uniqKey="Gutowski K">KA Gutowski</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Carter, Jc" uniqKey="Carter J">JC Carter</name></author><author><name sortKey="Church, Fc" uniqKey="Church F">FC Church</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Carter, Jc" uniqKey="Carter J">JC Carter</name></author><author><name sortKey="Church, Fc" uniqKey="Church F">FC Church</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Wyckoff, J" uniqKey="Wyckoff J">J Wyckoff</name></author><author><name sortKey="Wang, W" uniqKey="Wang W">W Wang</name></author><author><name sortKey="Lin, Ey" uniqKey="Lin E">EY Lin</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Claro, F" uniqKey="Claro F">F Claro</name></author><author><name sortKey="Morari, J" uniqKey="Morari J">J Morari</name></author><author><name sortKey="Moreira, Lr" uniqKey="Moreira L">LR Moreira</name></author></analytic></biblStruct></listBibl></div1></back></TEI><pmc article-type="case-report"><pmc-dir>properties open_access</pmc-dir>
<front><journal-meta><journal-id journal-id-type="nlm-ta">Plast Reconstr Surg Glob Open</journal-id><journal-id journal-id-type="iso-abbrev">Plast Reconstr Surg Glob Open</journal-id><journal-id journal-id-type="publisher-id">GOX</journal-id><journal-title-group><journal-title>Plastic and Reconstructive Surgery Global Open</journal-title></journal-title-group><issn pub-type="epub">2169-7574</issn><publisher><publisher-name>Wolters Kluwer Health</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">27104093</article-id><article-id pub-id-type="pmc">4801102</article-id><article-id pub-id-type="art-access-id">00005</article-id><article-id pub-id-type="doi">10.1097/GOX.0000000000000580</article-id><article-categories><subj-group subj-group-type="heading"><subject>Case Report</subject></subj-group></article-categories><title-group><article-title>Fat Grafting to the Breast, a Simple Procedure for a Very Complex Reconstruction</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes"><name><surname>Claro</surname><given-names>Francisco</given-names><suffix>Jr</suffix></name><degrees>MD</degrees><xref ref-type="aff" rid="aff1">*†</xref></contrib><contrib contrib-type="author"><name><surname>Pereira</surname><given-names>Fernando Linhares</given-names></name><degrees>MD</degrees><xref ref-type="aff" rid="aff1">‡</xref></contrib><contrib contrib-type="author"><name><surname>Pinto-Neto</surname><given-names>Aarão M.</given-names></name><degrees>MD, PhD</degrees><xref ref-type="aff" rid="aff1">†</xref></contrib><aff id="aff1">From the<label>*</label>Santa Cruz Plastic Surgery Institute (ICPSC), São Paulo, Brazil;<label>†</label>Department of Gynecology and Obstetrics, School of Medical Sciences, State University of Campinas (UNICAMP), Campinas-SP, Brazil; and ‡Ultrasound Unit, Department of Radiology, University of São Paulo Medical School, São Paulo, Brazil.</aff></contrib-group><author-notes><corresp id="c1">Francisco Claro Jr, MD, Instituto de Cirurgia Plástica Santa Cruz (ICPSC), Rua Santa Cruz, 398, 04122-000 São Paulo, SP, Brazil, E-mail: <email xlink:href="drfrancisco@franciscoclaro.com">drfrancisco@franciscoclaro.com</email></corresp></author-notes><pub-date pub-type="collection"><month>1</month><year>2016</year></pub-date><pub-date pub-type="epub"><day>18</day><month>1</month><year>2016</year></pub-date><volume>4</volume><issue>1</issue><elocation-id>e594</elocation-id><history><date date-type="received"><day>30</day><month>7</month><year>2015</year></date><date date-type="accepted"><day>2</day><month>12</month><year>2015</year></date></history><permissions><copyright-statement>Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved.</copyright-statement><copyright-year>2016</copyright-year><license license-type="open-access"><license-p>This is an open-access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by-nc-nd/4.0/">Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND)</ext-link>, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.</license-p></license></permissions><self-uri xlink:type="simple" xlink:href="gox-4-e594.pdf"></self-uri><abstract abstract-type="toc"><p>Supplemental Digital Content is available in the text.</p></abstract><abstract><title>Summary:</title><p>Usually, complicated reconstructions demand complex procedures. However, we report an unpublished situation where lipofilling was the only effective procedure for breast reconstruction, once 4 previous procedures, including 2 microvascular free flaps, had failed. The reported case describes a woman without subcutaneous tissue in the left breast topography, with radiation sequelae resulting in a fibrotic, hyperchromic, unexpandable skin that was tethered to her costal bone and pleura. The 4 previous attempts of breast reconstruction resulted in unavailable nearby recipient vessels, and this situation appointed breast lipofilling as the most feasible procedure. This report shows the power of breast lipofilling, a simple procedure that can be used even for the more complex reconstructions.</p></abstract><custom-meta-group><custom-meta><meta-name>OPEN-ACCESS</meta-name><meta-value>TRUE</meta-value></custom-meta><custom-meta><meta-name>SDC</meta-name><meta-value>T</meta-value></custom-meta></custom-meta-group></article-meta></front><body><p>Usually, the reconstruction of complex deformities of the breast resulting from oncological resection along with radiation sequelae of the surrounding area demands complex surgeries. However, a quite simple procedure may represent an important exception.</p><sec><title>CASE REPORT</title><p>A 44-year-old woman mastectomized due to a 3.5-cm infiltrative ductal carcinoma (GII-SBR, LUNINAL A, p53 negative) with 3 positive lymph nodes from 17 dissections (though a breast cancer with a high risk of recurrence) underwent immediate breast reconstruction of the left breast using latissimus dorsi myocutaneous flap along with silicone-filled breast implant. At the sixth postoperative month, after she had finished radiation therapy with cobalt and in course of adjuvant chemotherapy, she developed Baker III capsular contracture. Breast implant replacement and capsulotomy were performed after 1 year of breast reconstruction along with symmetrization of her contralateral breast, when the chemotherapy treatment was concluded. About 6 months after the second surgery, she developed Baker III capsular contracture again that was conducted with clinical treatment due to intense radiation damage to the skin. Eight months later, she was presented to us with breast implant rupture and extrusion after local trauma 2 weeks earlier. New surgical procedure was immediately performed to remove the breast implant; fibrotic and unexpandable skin was observed intraoperatively even over the latissimus dorsi flap. So, the site was exhaustively cleaned with saline solution and antibiotics, followed by primary closure.</p><p>A microsurgical breast reconstruction with deep inferior epigastric perforator flap was performed 1 year after breast implant removal. The atrophic latissimus dorsi flap was resected. The internal mammary vessels were used as recipient, because the thoracodorsal vessels of the latissimus dorsi flap were unsuitable for microvascular anastomosis. At the second postoperative day, the flap developed intense congestion that demanded re-exploration. A huge hematoma was found to be the cause of venous congestion. Salvage procedures were ineffective because the recipient vein was unable to re-establish flow and no other proper recipient vein was available at intercostal space, superior or lateral thorax. So, the flap was removed and primary closure was performed through traction maneuvers.</p><p>Six months after deep inferior epigastric perforator flap removal and almost 5 years after mastectomy, the patient still needed breast reconstruction. At this time, she had no subcutaneous tissue in the left breast topography, the skin was fibrotic, hyperchromic, unexpansible, and tethered to the costal bone. At the site where the fourth costal cartilage was removed to access the recipient vessels for the microsurgical anastomosis, the skin was tethered to the pleura and her respiratory movements were easily noticed (Fig. <xref ref-type="fig" rid="F1">1</xref>A and see Fig., Supplementary Digital Content 1, which displays a flowchart overview of the case report, <ext-link ext-link-type="uri" xlink:href="http://links.lww.com/PRSGO/A162">http://links.lww.com/PRSGO/A162</ext-link>).</p><fig id="F1" position="float"><label>Fig. 1.</label><caption><p>A, View of her left breast after 4 ineffective breast reconstruction attempts. There was no subcutaneous tissue in the left breast topography; the skin was fibrotic, hyperchromic, unexpansible, and tethered to the costal bone. At the site where the fourth costal cartilage was removed to access the recipient vessels for the microsurgical anastomosis, the skin was tethered to the pleura and her respiratory movements were easily noticed. B, View of her left breast at 3 years of breast lipofilling and 2 years of breast implant inclusion.</p></caption><graphic xlink:href="gox-4-e594-g001"></graphic></fig><p>After 4 ineffective breast reconstruction procedures, including 2 microvascular surgeries, lipofilling to the breast was proposed. Three sessions with average interval of 3 months between them were performed with a total of 440 mL of fat (centrifuged at 3000 rpm/3 minutes, grafted using 3-mL syringes and 1.8-mm diameter cannulas—120, 150, and 170 mL of fat were, respectively, grafted per session). Six months after conclusion of lipofilling, complete remission of skin radiation sequelae was observed and the skin was soft and elastic again (see Fig., Supplementary Digital Content 1, which displays a flowchart overview of the case report, <ext-link ext-link-type="uri" xlink:href="http://links.lww.com/PRSGO/A162">http://links.lww.com/PRSGO/A162</ext-link>) and with a minimum subcutaneous thickness of 2 cm at whole left breast topography (confirmed by ultrasonographyc and magnetic resonance imaging controls; see video, Supplementary Digital Content 3, which shows a complete remission of skin radiation sequelae. The skin is soft and elastic again at 3 years of breast lipofilling and 2 years of breast implant inclusion. <ext-link ext-link-type="uri" xlink:href="http://links.lww.com/PRSGO/A164">http://links.lww.com/PRSGO/A164</ext-link>). So, a silicone-filled breast implant was inserted in the left breast, and a mastopexy was performed at the right breast. After breast implant insertion, it was observed that over projection of the upper medial portions of the left breast resulted from the fullness of grafted fat (that was expected to have a partial absorption) and a lack of volume at the lower lateral portion. One year after this procedure, neither any absorption nor any sliding of the grafted fat over the implant toward the lower pole of the breast happened (Fig. <xref ref-type="fig" rid="F1">1</xref>B and see Fig., Supplementary Digital Content 1, which displays a flowchart overview of the case report, <ext-link ext-link-type="uri" xlink:href="http://links.lww.com/PRSGO/A162">http://links.lww.com/PRSGO/A162</ext-link>). So, a liposuction of the upper pole and additional lipofilling to lower and lateral portions of the left breast were proposed. However, she declined to undergo another surgery, stating that she was completely satisfied with her breasts.</p><fig id="V1" position="float"><label>Video 1.</label><caption><p>See video, Supplementary Digital Content 3, which shows a complete remission of skin radiation sequelae. The skin is soft and elastic again at 3 years of breast lipofilling and 2 years of breast implant inclusion. <ext-link ext-link-type="uri" xlink:href="http://links.lww.com/PRSGO/A164">http://links.lww.com/PRSGO/A164</ext-link>.</p></caption><graphic xlink:href="gox-4-e594-g002"></graphic></fig><p>At the moment, the patient is in the second postoperative year of breast implant inclusion and no clinical complication has been observed. She remains completely happy, with active social and sexual life at 52 years old. Clinical, mammographic, ultrasonographic, and magnetic resonance imaging controls have not shown any evidence of breast cancer relapse after 8 years of mastectomy and 3 years of lipofilling (Fig. <xref ref-type="fig" rid="F2">2</xref>). Curiously, trying to justify why she does not want to undergo an additional procedure to aesthetically improve her reconstructed breast, she sent me some pictures of her breast, showing how she and her boyfriend see her breasts while she is standing (left) and lying (see Fig., Supplementary Digital Content 2, an image sent from the patient displaying her reconstructed breast. Left, standing; right, lying. Observe the low mobility of the reconstructed breast when compared with the mammary tissue due to higher density of the grafted fat. <ext-link ext-link-type="uri" xlink:href="http://links.lww.com/PRSGO/A163">http://links.lww.com/PRSGO/A163</ext-link>).</p><fig id="F2" position="float"><label>Fig. 2.</label><caption><p>No clinical complication was observed after the breast implant inclusion. Controls have not shown any evidence of breast cancer relapse after 8 years of mastectomy, 3 years of lipofilling, and 2 years of breast implant. Magnetic resonance imaging controls (pictures above) show the maintenance of subcutaneous thickness without any sign of capsular contraction or radiological findings at the reconstructed breast.</p></caption><graphic xlink:href="gox-4-e594-g003"></graphic></fig></sec><sec sec-type="discussion"><title>DISCUSSION</title><p>The use of fat tissue for breast reconstruction has been described for more than 100 years.<sup><xref rid="R1" ref-type="bibr">1</xref>,<xref rid="R2" ref-type="bibr">2</xref></sup> Due to the high potential of neovascularization of the adipose tissue, some reports have been made of its effectiveness in treating radiation sequelae<sup><xref rid="R1" ref-type="bibr">1</xref>–<xref rid="R4" ref-type="bibr">4</xref></sup> However, a case of such complexity, where a lipofilling was the only effective procedure for breast reconstruction, when pedicle myocutaneous flaps and microvascular free flaps had failed, in a patient with fibrotic skin tethered to the costal bone and pleura without subcutaneous tissue or near recipient vessels, has not been published before.</p><p>This case shows the power of lipofilling to the breast as an effective procedure able to revert radiation sequelae, allowing aesthetic scars, without donor site deformity, with low complexity, and low cost.<sup><xref rid="R1" ref-type="bibr">1</xref></sup> The questioned oncological risk of fat grafting to the mammary gland was stated<sup><xref rid="R5" ref-type="bibr">5</xref>,<xref rid="R6" ref-type="bibr">6</xref></sup> based on theoretical hypothesis regarding the obesity and reported in “in vitro” experiments with adipocytes,<sup><xref rid="R7" ref-type="bibr">7</xref>–<xref rid="R10" ref-type="bibr">10</xref></sup> and remains not sustained in clinical practice.<sup><xref rid="R1" ref-type="bibr">1</xref>,<xref rid="R2" ref-type="bibr">2</xref></sup> However, it was reported that the mature adipocytes of the breast represent a true potential for breast cancer,<sup><xref rid="R8" ref-type="bibr">8</xref></sup> and the fat grafting procedure by itself is not able to induce any oncological risk.<sup><xref rid="R10" ref-type="bibr">10</xref></sup> This means that the grafted fat does not seem to increase the risk of breast cancer if we take into account that the native unmanipulated adipocytes of breast have their own paracrine activity over the glandular cells.</p></sec><sec sec-type="supplementary-material"><title>Supplementary Material</title><fig id="s1" position="anchor"><media xlink:href="gox-4-e594-s001.pdf"></media></fig><fig id="s2" position="anchor"><media xlink:href="gox-4-e594-s002.pdf"></media></fig><fig id="s3" position="anchor"><media xlink:href="gox-4-e594-s003.mp4"></media></fig></sec></body><back><fn-group><fn fn-type="financial-disclosure"><p><bold>Disclosure:</bold> The authors have no financial interest to declare in relation to the content of this article. 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