Our initial use of breast lipomodeling was as a simple complement to breast reconstruction. Due to the remarkable efficacy we have observed, this technique has quickly taken a central place in breast plastic surgery and it is currently used in various indications. The experience gained with this technique allowed us to obtain excellent results that were not possible with conventional techniques. In addition, breast lipomodeling indications have gradually expanded and have completely changed the indications of breast plastic and reconstructive surgery, as well as breast cosmetic surgery.
This experience gained over the years has led us to expand the possibilities of breast reconstructive surgery and thus expand our therapeutic range, due to more and more complex cases that were referred to us by our fellow plastic surgeons. These rare and difficult cases (Eg. major malformations, major sequelae of breast cancer, sequelae of traumatisms of the breast, sequelae of infection of the breast, sequelae of surgery of the breast), for which the surgeons wanted to give the best possible treatment outcomes to the patients, often presented real therapeutic challenges and stimulated our surgical creativity.
In parallel with these therapeutic advances in reconstructive surgery, and using appropriately selected cases, new applications in cosmetic breast surgery were developed that achieved very good results without requiring the use of an implant. All indications presented here have been used in my daily clinical practice and have been validated by intense surgical activity. Each indication is the subject of a detailed comment allowing us to put into perspective the interest of lipomodeling and fat transfer to the breast, in each indication of plastic, reconstructive and aesthetic breast surgery.
In breast reconstruction, breast lipomodeling, or fat transfer to the breast, can be used whenever it is desired to correct a localised defect (subcutaneous depression) on a reconstructed breast, or to achieve a volume complement of the reconstructed breast. The cleavage area, so fundamental for patients in social life (to the point that we called it “social breast”), is the ideal area for this transfer of adipose tissue.
Lipomodeling improves volume, shape, projection, consistency, and contours of the breast. At the level of the breasts reconstructed by flaps, the addition of fat can bring a large volume and can contribute to maintain the purely autologous character of the reconstruction, and thus to avoid an implant that brings its own drawbacks, especially after radiotherapy.
Autologous Latissimus Dorsi Flap reconstruction (ALDF)
In terms of breast reconstruction, the goal of the plastic surgeon is to obtain a reconstructed breast of natural shape and consistency, that closely approximates the contralateral breast. The use of an autologous reconstruction avoids the complications of the prostheses and allows modeling of the flap. This allows a reconstruction of a breast close to the contralateral breast, thus obtaining a reconstructed breast that will be more stable over time and allow a better integration into the patient’s body diagram. Developed by our team in 1992, applied in clinical practice since 1993, and gradually improved over the years, the non-prosthetic Latissimus Dorsi Flap (or autologous latissimus Dorsi flap ALDF) has gradually surpassed in our practice the use of TRAM Flap and DIEP over the last ten years. It allows much simpler postoperative operation, better management of local chest tissue and avoids the effect of patch of skin transferred on the breast (patch effect). The Latissimus Dorsi Flap without implant, following the technical improvements proposed in the recent years (SSLD), has established itself as the best autologous breast reconstruction technique in terms of reliability, safety and final quality of the results.
In some cases, in the past the volume of the reconstructed breast could be insufficient because of a very thin patient, or a significant atrophy of the flap. In these cases, the classical solution was the secondary placement of an implant under the flap, changing the purely autologous nature of the reconstruction resulting in a less natural shape and creating its own disadvantages. In other cases, although the result is generally good, there may have been a lack of projection or a localized deficit (mainly in the super-medial region of the breast, area of the neckline) which was detrimental to obtaining a high-quality breast reconstruction.
The possibility of performing a lipomodeling of the reconstructed breast has brought a significant advance (or even major) and allows us to perform an autologous breast reconstruction in the vast majority of cases (98% of cases). Only really thin patients, without any fat that can be harvested will not benefit from this technique, or those who already have a contralateral augmentation implant; in these rare cases, the other techniques are also difficult to use. The lipomodeling offers advantages: purely autologous character of the reconstruction, reproducibility and safety of the technique in trained hands, possibility of repeating the lipomodeling in cases of poorer results or particularly difficult cases and especially the possibility of obtaining a breast of natural appearance and consistency +++, very close to the contralateral breast. The Latissimus Dorsi Flap without implant is the most suitable tissue to receive grafts of adipose tissue as it is very well vascularised. The muscle tissue and the adjacent adipose areas constitute suitable tissues to generate an excellent revascularisation quality of the grafted adipocytes.
At the level of the Latissimus Dorsi Flap without implant, the quantities transferred can be very important. At the beginning of our experience we carried out moderate transfers of fat, in the order of 100 to 120 ml. Given the resorption rate, the efficacy was insufficient and lipomodeling then mainly used to correct localized abnormalities or defects located at the neckline. Experience has shown us that very large quantities can be transferred to this indication, and transfers in one session of up to 500 ml per breast (for an already large breast volume) per session, have been performed with very good results.
The transfer is performed from the deeper zone to the surface. It begins from the costal plane to go up in the Pectoralis Major muscle, then in the reconstructed breast, to the subcutaneous plane. It is necessary to create many different tunnels, making a real three-dimensional mesh. In areas where the tissue thickness is limited with major subcutaneous depression it is better to return several times, possibly under local anesthesia for small session.
We understand here the advantage of having the Latissiums Dorsi Flap all over the mammary base because the Latissiums Dorsi Flap is now conceived as an auxiliary (concept of the “spaghetti box”, which we proposed, to make clear the way to proceed) that will prepare the mammary recipient site for the future lipomodeling ++++ (recipient matrix for the transplant of fat tissue), this is particularly true in very thin patients for whom the expected final volume (after 5 months, corresponding to the time of muscle atrophy) is low. In these cases, having spread and managed our flap with the idea of making it a future lipomodeling recipient site, allows us to well prepare the fat transfer. In patients in whom the flap is very muscular we perform the lipomodeling quite early (at 2 months), before the maximal atrophy, in order to take advantage of the volume effect, which allows receipt of enough fat (concept of the “spaghetti box”: you must have a box of sufficient volume to receive many “fat” spaghetti).
This technique is very well accepted by patients who see the effectiveness, and understand the concept of this intervention. The morphological results are considered very good by the objective evaluation made by the surgeons, and the patients are very satisfied with this intervention, which improves the reconstructed breast and makes it possible to obtain excellent final results, while decreasing unwanted “fat” zones. For cases deemed insufficient or initially very difficult, patients understand very well that it is necessary to return several times and that it is a stage surgery (“technique of small steps”), each step participating in gradual improvement of the result.
Large Latissimus Dorsi Flap reconstruction with implant
As we saw above, in our team we prefer to use the latissimus Dorsi Flap without implant, which allows us to obtain the best possible results in breast reconstruction in very trained hands, and avoids the need of any implant with their disadvantages. However, the Latissimus Dorsi Flap with implant is still indicated in rare cases. In our team, Latissimus Dorsi Flap with implant is indicated in the case of very thin patients, patients wishing to keep a large breast volume while their dorsal and overall adiposity is not important, or in cases in which the patients had a contralateral breast augmentation with implant. Other surgeons prefer to keep the Latissimus Dorsi Flap technique with implant because they have not been trained in the Latissimus Dorsi Flap technique without implant, or others are familiar with the Latissimus Dorsi Flap technique with implant and have already achieved good results and do not want to go through the learning curve +++ (about 50 reconstructions) necessary to perform the autologous technique. Finally, in older cases, dating back to the period preceding the autologous technique, the patients consulted us for an improvement of the result, or a change of implant.
Lipomodeling of the breast can then be used to correct a localized defect (often at the neckline or the external region), to improve the neckline, or to reduce the risk of hull during the change of implant. After lipomodeling of the Latissimus Dorsi Flap plus implant, it is advisable to consider at the same time the change of implant +++ (make a prior agreement for partial coverage by the health insurer) as the lipomodeling can potentially lead to trauma of the implant. Also, the best indication of a Latissimus Dorsi Flap lipomodeling plus implant is when considering a change of implant (in case of hull, insufficient result, or old implant). Usually, in the secondary cases the patients really appreciate the improvement of the flexibility, the improvement of the consistency of the breast, and especially the improvement and sensitivity and the “natural” aspect of the reconstructed breast.
Lipomodeling of reconstructed breast by implant or Composite Breast Reconstruction
The defects of breast reconstructions by prostheses are mainly of three types: defect of the neckline with staircases at the upper part of the breast and asymmetry of the cleavage compared to the contralateral breast, internal defect with effect of staircases and intermammary furrow too wide, and finally external defect with hollow at the external part of the breast, just below the anterior axillary line.
As a result of the experience gained initially in the lipomodeling of reconstructed breasts by Latissimus Dorsi Flap without implant, we very quickly transposed this experiment to reconstructed breasts with prostheses, performing a Composite Breast Reconstruction. The technique consists of transferring the fat to the cleavage, that is to say to the super-internal part of the breast, here the lipomodeling is mainly intra pectoral. At the level of the internal part of the breast, the lipomodeling is intra pectoral and between the skin and the capsule when the lipomodeling is made during a change of implants. At the external level, the lipomodeling is between the skin and the capsule and can only be performed when it is a change of implants.
Experience has shown us that the best results are obtained when the lipomodeling is combined with a change of implants, because it can act on the three defects found during breast reconstructions with implants. The quantities transferred here are smaller and range from 100 to 200 ml, depending on the recipient tissues and the local trophicity, and in particular the trophicity of the Pectoralis Major muscle. The tissues being less vascular than those of the Latissimus Dorsi Flap without implant, it is necessary to less saturate the tissues with fat to ensure a satisfactory fat grafting. It is also interesting to perform a lipomodeling during the primary reconstruction with implants (especially at the neckline) if we do not consider an implant change, however the studies conducted in our team have shown less positive results.
The results of our series have shown no complication inherent to this technique, knowing that we apply the precautionary principle, which is “if the lipomodeling reached near the implant, we recommend a systematic change of the implant” to not risk leaving an implant in place that would have been traumatized by the transfer cannula. The results showed a good acceptance of the technique by the patients and a high satisfaction of the patients and the surgeon. This technique makes it possible to obtain results that were impossible to obtain by the use of an implant alone +++. On the other hand, fat transfer reduces the risk of hull and recurrence of hull, and allow to obtain more stable results over time without having a progressive degradation of the results, as it is traditional to observe in the reconstructions with implants from the fifth year onwards (see the very good work of KB Clough – Paris, who had clearly shown the deterioration of the results of reconstructions with implants after 5 years).
Reconstruction by TRAM
Although TRAM is considered as one of the techniques giving very good results in breast reconstruction defects can also appear after using this technique; in particular volume asymmetries, a lack of projection or a cleavage defect related to atrophy of the upper part of the Pectoralis Major, secondary to the joint action of axillary dissection and parietal radiotherapy.
We have applied the lipomodeling technique to the breast reconstruction by TRAM, since 2000, for our own cases, or for secondary cases. During secondary reconstructions we perform an intra pectoral lipomodeling and a lipomodeling of the flap by insisting on the areas which present a lack of fullness and a depression. In some cases, a lipomodeling aiming at increasing the overall volume of the flaps was done without any particular difficulty. In these cases, transfer a little less fat than you could in a Latissiumus Dorsi Flap without implant, because the TRAM is less vascularised and this can easily lead to more risk of fat-necrosis.
In this indication, I did not find any complication inherent to this technique and the desired goals were obtained: an improvement of the overall shape of the breast, an improvement of the upper part of the neckline and final results considered very good. In the case of a TRAM, the lipomodeling is particularly relevant because the abdominal and latero-abdominal fat harvesting allows fine improvements at the abdominal and latero-abdominal area, giving a more global harmonization of the thoracoabdominal region, particularly appreciated by patients. Especially for the secondary cases with defect of the upper part of the breast this technique makes it possible to avoid moving the flap and thus reduces the risk most feared, necrosis of the flap (which would be dramatic), a complication always possible during secondary displacement of the flap.
Breast Reconstruction by DIEP
Breast reconstruction by DIEP has been the subject of numerous papers and articles in recent years, in which promoters have often presented this technique as the most advanced, and the most modern technique. This is, in my opinion, more “marketing” than scientific reality. In fact, it is not really a new technique. In 1991 I had devoted my final dissertation from Plastic Reconstructive Surgery and aesthetic studies to « free flaps in breast reconstruction », and this technique was already well presented in this work. It consists of transferring the lower abdominal cutaneous-fat palate to perforating vessels from deep inferior epigastric vessels, and then to re-anastomosing them by microsurgery in the internal mammary vessels. This intervention, very beautiful technically, requires a microsurgical time, which lengthens the intervention and exposes to a risk of necrosis and loss of flap with its dramatic consequences for the patient, and very anxiety-provoking for the entire surgical team +++. In 1991 I thought that this intervention would develop, as I wrote in my memoir. In 1992, when I visited one of my colleagues who specialized in breast reconstruction and microsurgery and considered one of the best micro-surgeons in the world, this confrere had to face a difficult case with microsurgery not going as well as expected when at 8 pm (for an intervention started at 8 am), the intervention was still in progress. Following this visit, I had to review my surgical strategy, and then I thought better, and understood that the free flap breast reconstruction (DIEP, or buttock flap) if it could provide an elegant solution in some special cases, it could not become a first-line technique to treat the many cases of breast reconstruction. Putting this into perspective, in France each year 20,000 patients undergo a mastectomy +++ (initial mastectomy during the initial breast cancer, or mastectomy for recurrent conservative treatment). It was therefore necessary to work on a technique that is more reliable and achievable in the normal way in the private sector or in the hospital sector, but with reasonable means and with a more acceptable operating time. In a contemporary way, one of my colleagues Dr. Patrick Zlatoff, renowned oncologist surgeon, told me while I was presenting a conference that I prepared on the TRAM: “you would have to find a technique that gives a result like a TRAM or a DIEP, but which is less heavy and has the reliability of a Latissimus Dorsi “. All of these elements made me orient my research on the development of the Latissimus Dorsi Flap without implant and preferentially developed this technique, keeping the reconstruction by free flaps only for exceptional cases that can not be treated by pedicle flaps. Especially in delayed breast reconstruction, the DIEP, like the TRAM, give a “patch” effect on the breast that is unnatural, and less attractive than with the Latissimus Dorsi Flap combined with the abdominal advancement flap with total burial of the flap.
Done well, and without unpleasant complications, the DIEP can give good or very good results in breast reconstruction but defects can appear, especially volume asymmetries, a lack of projection or often a defect in the neckline. We applied the lipomodeling to DIEP breast reconstruction, mainly for secondary cases, in patients who were not completely satisfied with the result, and who consulted us to consider an improvement and to go back over the reconstruction. The technique is exactly the same as after breast reconstruction by TRAM: we perform an intra pectoral lipomodeling and a lipomodeling of the flap, insisting on the areas that have a lack of fullness and a depression. In some cases, the lipomodeling, aiming to increase the overall volume of the breast has been achieved without particular difficulty.
The results obtained were very satisfactory with an improvement of the overall shape of the breast and an improvement of the upper part of the neckline. In the case of the DIEP, the lipomodeling is particularly relevant because the fat harvesting in the abdominal and latero-abdominal areas allows fine retouching of the abdominal site giving a more comprehensive harmonization of the thoraco-abdominal region, particularly popular with patients. For secondary cases with defect of the upper part of the breast, this technique makes it possible to avoid moving the flap and avoids the dreaded risk of complications such as total necrosis of the flap, of which I have been reported a case with its dramatic consequences for the patient and her surgeon. Finally, I was confronted with a patient who had benefited from a bilateral breast reconstruction by DIEP but unfortunately one of the two DIEP, although made by one of the best European teams, had undergone necrosis. I was able to achieve the recovery of this reconstruction by an exclusive lipomodeling (see this chapter) and allow this patient to obtain an autologous breast reconstruction of good quality, despite this unfortunate and very unpleasant complication.
Breast Reconstruction by Exclusive Lipomodeling
Given the enthusiasm generated by the lipomodeling in our team, we developed in 2001, breast reconstruction by lipomodeling only (it is weird to see some present this technique as a novelty and to be “lathered” in presenting it as a recent advance!) This technique has also been developed (since 2006) with great enthusiasm and energy by Dr. Roger Khouri, inventor of Brava (see chapter) and Dr. Gino Rigotti, who have expanded the indications with the joint use of Brava, in order to prepare and distend the local tissues. It is mainly applicable to patients with contralateral breast volume of small volume, and having steatomeries that can be harvested (typically patient thin at the top and fat around the lower body). The technique consists in reconstructing the breast in several operating times, using exclusively the transfer of fat. In the indications defined above, it takes 3 to 4 sessions of lipomodeling to obtain a breast in relation to the contralateral volume, if the patient did not have radiotherapy, and 5 to 6 sessions if the patient had parietal radiotherapy. This therapeutic protocol has been evaluated (we published a recent article on this subject in a leading American journal: Clinics in Plastic Surgery 2017), and it is very interesting for particular cases of breast reconstructions in patients with low breast volume, or in cases of breast reconstruction failure catch-up. When the breast volume is larger, the use of Brava and the multiplication of sessions allow to achieve this, but it is often better to start the initial matrix (the “spaghetti box”) by a Latissimus Dorsi Flap without implant, or a perforating flap, to allow the reconstruction in a reasonable number of procedures. It takes all the finesse of long clinical experience of the operator to provide good indications +++, and allow the project to be completed.
The exclusive lipomodeling reconstruction is finally a technique of choice when it is possible for secondary cases. Thanks to our experience, difficult cases are regularly addressed to our team, after failure of other techniques with the result of complications occurring in other teams,. When the main classical solutions have been used, the lipomodeling then provides a “miraculous” solution for the patients, because it allows in a few simple and low risk interventions, to leave this therapeutic impasse. This allows a quality reconstruction, without scarring, and the potential risk of failure of a new flap, which should then be a free flap, subject to the natural hazards of microsurgery. I was also confronted with cases of patients who, although having had a reconstruction that seemed technically successful (that is to say without complication), rejected the new image of a reconstruction with implants, which seemed to them unnatural, too big, and “artificial”. After several consultations to properly assess the patient’s demand in these particular cases, and to try to predict if they could be satisfied with the new body image proposed, it is then possible to replace (in favorable cases) the implant by an iterative lipomodeling, for patients with small breasts.
Pectoro-mammary flap breast reconstruction
The pectoro-mammary flap was developed in 1998 in our team. It is still rarely used, however it should be used more often. It consists of reconstructing the skin of the breast by an abdominal advancement flap, and the volume of the breast by a part of the contralateral breast vascularised by the acromio-thoracic pedicle. The indications must be precise. Different conditions must be met: good quality and well vascularised abdominal advancement flap, hypertrophied contralateral breast, and low cancer risk of contralateral breast (because contralateral breast is transferred, and we can not transfer a diseased breast). This technique is elegant in very good indications. In order to complete the volume of the reconstructed breast and improve its shape, the lipomodeling is used during the second operating time to improve one or the other breast and obtain the best possible reconstruction. Before performing a pectoro-mammary flap, an accurate imaging assessment is carried out in order to eliminate a contralateral breast lesion, of which some part will be used as a flap. Similarly, after the intervention, an accurate imaging assessment is carried out to allow radiological monitoring, which becomes bilateral again with this technique. The advantages of this technique are to avoid the use of an other flap, and to give a breast of very natural consistency.
Lipomodeling to prepare local tissues
When the skin is very thin, or very damaged by radiotherapy and there is a fear of cutaneous necrosis during the breast reconstruction time, it is possible to perform, approximately 3 months before the actual reconstruction time, a lipomodeling to prepare the reconstruction, transferring 80 to 200 ml of fat to the damaged and thin thoracic tissues. The trophicity of the skin is improved, and this often makes it possible to avoid cutaneous necrosis, dreaded and difficult to manage even in cases of autologous breast reconstruction. In the same spirit, it is possible in some cases to prepare the skin and thicken the subcutaneous tissue to allow the use of an implant in cases of limited indications where a flap would be technically preferable, but which the patient does not want but prefers to try the use of an implant, at least initially.
Symmetrization and lipomodeling
Lipomodeling allows in certain cases to symmetrize the contralateral breast, in particular by improving the cleavage by an intra-pectoral and upper breast lipomodeling, by increasing very slightly the contralateral breast volume. In this indication, an accurate pre-operative imaging assessment is performed (mammography and ultrasound), with a 1-year imaging check up by the same radiologist. According to the SOFCPRE recommendations, this indication is currently reserved for multidisciplinary teams highly trained in lipomodeling, diagnosis and breast cancer follow-up, in order to limit the risk of coincidence with contralateral breast cancer.
Lipomodeling of symmetrisation
After breast reconstruction, it is desirable to keep a stable weight to keep the symmetry as good as possible. In some cases, the patient’s weight changes over time, sometimes with contralateral breast volume loss, resulting in asymmetry. In other cases, the hormonal treatments prescribed for breast cancer can cause a change in the volume of the breast. Finally, in rare cases the reduction of the contralateral breast for symmetrisation has been a little too marked, and the reduced breast is then too small. For these cases, we were quite helpless before the lipomodeling technique. It is now possible to simply restore contralateral breast fullness and improve breast symmetry. In this indication, an accurate pre-operative imaging assessment is performed (mammography and ultrasound), with a 1-year imaging check up by the same radiologist. According to the SOFCPRE recommendations, this indication is also currently reserved for multidisciplinary teams highly trained in lipomodeling, diagnosis and breast cancer follow-up, in order to limit the risk of coincidence with possible contralateral breast cancer.
The tuberous breasts are a malformation of the breasts, corresponding to an abnormality of the mammary base, which is revealed at puberty at the time of the growth of the breast volume (see this chapter in chirurgie-esthetique-du-sein. fr). Different surgical approaches have been described, and there are a variety of techniques to achieve the best possible result. Among these techniques, the lipomodeling makes it possible to correct the lack of volume (especially if the lack of volume is unilateral), to improve the base, and even to modify the shape of the breast. It thus appears that lipomodeling is a very interesting complementary technique in the treatment of tuberous breasts. We have been using lipomodeling since 2000 in tuberous breasts, and the long-term results are very interesting with unexpected results with the other techniques, in terms of quality of the results and natural results. Coleman also published in 2007 very pleasing results of treatment of tuberous breasts by transfer of fat in the breasts. One of my very famous friends in the treatment of tuberous breasts told me one day after a presentation at the SOFCPRE “your results are superb, but you use fat transfer in the breast that I do not use”. I replied: “Use them! You will transform the quality of your results, and you will avoid many long-term implants replacement to your patients “.
The best indications are represented by the unilateral hypotrophic tuberous breast (which generally requires 2 sessions of fat transfer), the lack of fullness of the upper pole of the breast, and the bilateral cases in young girls who develop at puberty an important trochanteric steatometry. On the other hand, breast implants remain a solution of choice for the treatment of tuberous breasts with bilateral hypotrophy in patients with low adiposity. Very often, in these cases, it is desirable to combine the augmentation by implants with a lipomodeling, by performing a composite breast augmentation, which in these cases makes it possible to obtain the best possible results.
In the tuberous breasts, each case is particular, and it is the fine analysis of the deformation that allows the finest indication, and ultimately the best result possible. The experience here is fundamental. Given the relative rarity of tuberous breasts; the complexity of the clinical forms, and the variety of therapeutic possibilities it may be wise to address these girls (for which we must try to give the best possible result) to an operator particularly experienced in this field (in tuberous breasts, and in Lipomodeling). We have done a lot of scientific work on this topic, including an article published in Aesthetic Surgery Journal.
The correction of thoracic and breast malformations of the Poland syndrome is still a challenge for the plastic surgeon (see this chapter in chirurgie-esthetique-des-seins.fr). In this malformation, the lipomodeling appears a major advance. Lipomodeling provides excellent breast reconstruction at the cost of repeated interventions, but with simple follow-up and low scarring. This is an exciting subject, and we have been fortunate to open this new therapeutic way, and to publish several international articles on this topic, including one in Aesthetic Plastic Surgery. In our experience, an average of 3 sessions were required to obtain the expected result; with an average of 244 ml of fat transferred in each session. The results are very interesting and allow us to reconstruct the breast almost identical to the contralateral breast. It seems that this technique constitutes a real revolution in the management of the thoraco-mammary malformation of the Poland syndromes, and is really a major step in the treatment of this exceptional malformation.
As for the tuberous breasts, each case is particular, and it is the fine analysis of the deformation that allows the finest indication and ultimately the best possible result. Experience is fundamental here. Given the great rarity of the Poland syndrome (1 in 30,000) and the complexity of the clinical forms, the learning curve is difficult to obtain, it would seem essential that these girls are addressed to a particularly experienced operator in the treatment of the Poland syndrome, lipomodeling and fat transfer to the breasts.
Pectus Excavatum and lipomodeling
Pectus excavatum is a complex malformation of the sternocostal breastplate corresponding to anterior-posterior depression. The functional impact of the pectus excavatum is usually zero or minimal, and in most cases, it is essentially a morphological and aesthetic problem. The repercussion on the breast position is important if the pectus excavatum is very marked, especially in lateralized forms. Fat transfer techniques allow for a satisfactory correction particularly for light and medium forms, or in combination with a rigid implant tailored with the help of the CT scan for major forms. It usually takes 2 lipomodeling sessions to get a good result; 3 sessions in major forms. We published an article on this topic in an American journal Aesthetic Surgery Journal.
Hypotrophic breast asymmetries, with satisfactory contralateral breast, are one of the ideal indications of lipomodeling and fat transfer to the breast. Indeed, before lipomodeling, it was necessary to use a silicone breast implant which when it was used unilaterally resulted after a few years in a new asymmetry of both shape and volume because the breast with implant does not evolve the same way as the normal contralateral breast. We have been using lipomodeling since 2000 in this indication and the long-term results are very interesting with almost perfect symmetry and a very natural appearance and consistency. On the other hand, the integration into the body diagram is really easy without the psychological risk of a rejection of the foreign body symbolically represented by the breast implant. Finally, the acquired result is durable, and avoids many interventions of implant replacement during life. It is also surprising that health insurances have, for years, preferred to pay for an augmentation using implants to treat asymmetries, rather than a correction of the asymmetry by natural increase of the breast using fat transfer. Fortunately, there is now a code in the French Insurance (CCAM) for this intervention.
Severe unilateral agenesis and hypotrophy
The correction of severe unilateral agenesis and hypotrophy is similar to the correction of thoracic and breast malformations of Poland syndrome. In these malformations, the lipomodeling appears, also, as a major advance. It allows us to obtain a breast reconstruction of excellent quality at the cost of simple repeated interventions. In our experience, 2 to 3 sessions are necessary, depending on the severity of the case, to obtain the expected result; with an average of 250 ml transferred in each session. The results are very interesting and allows us to reconstruct the breast almost identical to the contralateral breast. This technique, when it is possible, due to the fat potential of the teenager, is a major advance in treating these malformations. The long-term results are very interesting with almost perfect symmetry and a very natural look and consistency. The integration in the body diagram is excellent because the breast growth is done gradually and is close to the physiological growth of the breast at the time of puberty. Finally, the obtained result is durable, and avoids several interventions of implant replacement during the person’s life with their associated risks and disadvantages.
Chest malformations and thoracic asymmetries
In some cases, lighter chest malformations, often related to scoliosis, may result in lighter thoracic and breast asymmetry that can be easily corrected with the lipomodeling technique. These malformations were often not corrected in the past and they were advised to stay “like that” because the disadvantages of other techniques (implant or flap) were too major compared to the deformation and the ratio of benefits / risks was not favorable. With the lipomodeling technique these lighter malformations can be easily treated and it is then possible to take care of these young patients, and to improve their well being affected by these malformations. Lipomodeling thus also makes it possible to broaden the therapeutic arsenal of the plastic surgeon.