L. Streit 1,2; L. Dražan 1; P. Novák 1; M. Schneiderová 3; Z. Dvořák 1; K. Teplá 2; J. Veselý 1
Department of Plastic and Aesthetic Surgery, St. Anne's University Hospital Brno, Brno, Czech Republic
1; Department of Plastic and Aesthetic Surgery, Faculty of Medicine, Masaryk University, Brno, Czech Republic
2; Department of Radiology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
ACTA CHIRURGIAE PLASTICAE, 58, 2, 2016, pp. 70-76
Congenital hypoplastic breast anomalies usually manifest during puberty and may have a negative impact on personal and social life of the young women. These patients can suffer from feelings of inferiority, peer rejection, low self-esteem and psychosocial dysfunctions. They may avoid to participate in school and sport activities which results as a negative impact on their psychosocial development 1.
Poland’s syndrome is a chest wall deformity characterized by complete or partial absence of the pectoral major muscle, often associated with ipsilateral upper limb malformation. Alfred Poland described this condition in 1841 2. The incidence is globally estimated to 1 in 30.000 newborns. Males are more frequently affected with severe forms then females, but less expressed form are more commonly observed in female patients 3. Upper limb malformation may be highly variable, although the most common are soft syndactyly and hypoplasia of the middle phalanges of the hand. Fourcas demonstrated that hand malformation was present in only 12% in Poland’s syndrome, and thus he proposed classification of Poland’s syndrome based on the degree of pectoral muscle hypoplasia, costal malformation and breast hypoplasia 3 :
Grade 1: Minor malformation with pectoral muscle hypoplasia and with breast hypoplasia in female patients which is expressed as discrete breast asymmetry
Grade 2: Moderate malformation with significant aplasia of the pectoral major muscle, significant breast hypoplasia or aplasia causing considerable breast asymmetry in female, and potentially with moderate costal malformation
Grade 3: Severe malformation with complete pectoral muscle aplasia associated aplasia of other muscle, breast aplasia in female patients, thoracic deformity with major costal malformation or sternal deformity. A major asymmetry of the thorax is evident.
Mestak estimated that Poland’s syndrome represented 14% of hypoplastic breast anomalies 4.
Tuberous breast is a breast shape deformity which was described under various names such as tuberous breast 5, tubular breast 6, herniated areolar complex 7 or narrow-based breast 8. Deformity is caused by insufficient development of the breast base when the preserved mammary gland is enveloped by fibrous connective tissue called aconstricting ring. Residual central part of the gland is expanding during puberty and thus typical tubular herniationof areolar complex may occur. We use Grolleau’s classification that defines individual types depending on which quadrants of the breast are undeveloped 9 :
Type I: Only the lower medial quadrant is deficient – lateral part of the breast appears oversized in comparison.
Type II: Both lower quadrants are deficient and subareolar cutaneous segment is short.
Type III: All four quadrants are deficient and breast base is constricted both horizontally and vertically. In typical forms, breast is shaped like a tubercle.
Correction of hypoplastic breast malformations is still challenging. And variety of surgical approaches has been described. The aim of this paper is to demonstrate benefits of lipomodelling technique based on our case series and literature review.
PATIENTS AND METHODS
From January 2013 to January 2016, three patients with hypoplastic congenital breast anomalies were operated exclusively by lipomodelling in our department.
Patients and their parents were informed of the advantages and drawbacks of lipomodelling procedures, its complications, and potential risks. They also consented for postoperative ultrasonography examination. On the contrary, ultrasound was an integral part of the preoperative examination prior to the second or other following session of lipomodelling procedures. A precondition for the next session of lipomodelling was benign finding on ultrasound examination after a previous session of lipomodelling (BI-RADS 1 or 2) with no significant fat necrosis. The main inclusion criteria were sufficient adipose tissue deposits and stable weight preoperatively. Contraindication for the surgery was positive family history of breast cancer, ovarian cancer in first degree relative or patients with a confirmed mutation in BRCA 1,2 gene. Preoperative photographs were taken.
All the procedures were performed under general anaesthesia by a single surgeon (main author) and the result was achieved in the following sessions. Respecting patient’s wishes and adipose tissue distribution, donor area included the hips, lower abdomen, trochanter area, inner thighs, inner knees, and also the lumbar region. Low-volume tumescent liposuction was applied (500–750 ml of normal saline with 1:500 000 of epinephrine) according to the protocol of adipose tissue harvesting for lipofilling 10. We used manual liposuction applying negative pressure by gradually withdrawing the plunger of a 30-ml Luer-lock syringe. We used harvesting cannulas of 3.5 mm in diameter and 17 cm in length (model PLA187, Pouret Medical, France). Lipoaspirate was processed by centrifugation at 1200g for 3 minutes at room temperature directly in 30-ml syringes. Upper oil layer and bottom aqueous layer were removed and complete adipose layer was used for fat transfer.
Processed fat is applied to the thoracic recipient area through several incisions that were made with the sharp bevel of a 17-gauge trocar. 2-3 of them are usually placed in the submammary fold and 2 in areola. Purified fat is transferred directly to the breast region using 10ml syringes with special 2mm transfer cannulas (PLA188, PLA189, Pouret Medical, France). Fat is injected in small quantities while pulling the cannula out in many directions. Transfer is done from deep to a superficial layer. Each microtunnel must be designed to be surrounded by awell-vascularized tissue to avoid creating areas of fatty pools, which could result in fat necrosis. It is essential to overcorrect volume of injected fat, if it is allowed by recipient tissues. Absorption of around 30–40% of the transferred volume can be expected. On the contrary, when the recipient tissues are saturated, further fat injections can cause development of fat necrosis. It is better to schedule an additional session rather than disregard saturation of the tissues.
Multiple fasciotomies with 17-gauge needle are the advanced modeling elements that allows to release subcutaneous fibrous septa percutaneously and thus enables to move the submammary fold downwards, sculpture the lower part of the breast, correct areolar herniation in tuberous breast and finally to shift areolar complex downwards in Poland’s syndrome.
All the patients were examined 1) clinically 2 weeks postoperatively after each session of lipomodelling, 2) clinically and by ultrasound shortly before next session of lipomodelling, and finally 3) clinically and by ultrasound at least 6 months after final session of lipomodelling. Photographs were taken during each follow-up visit. We evaluated a number of lipomodelling sessions, volumes of transferred fat and degree of fat resorption. The size, and the number of fat necrosis were evaluated on sonography by a single radiologist.
From January 2013 to January 2016, three patients with hypoplastic congenital breast anomalies were operated exclusively by lipomodelling in our department (1 patient with Poland’s syndrome, 2 patients with tuberous breast). Average of 2 sessions of lipomodelling were needed for achieving desired size of the breast in acorrection of tuberous breast deformity and 5 sessions for the breast reconstruction in Poland’s syndrome. The minimum time inter-val between individual surgeries was 3 months. Mean follow-up was 15 months (6–26 months). We achieved breast with a natural appearance and consistency with abra cup size B–D. We observed no surgical complications; there was not any palpable masses in the breast after lipomodelling.
Before the second and every subsequent session, preoperative ultrasonography examinations have showed homogeneous tissue of the operated breast with several small zones of cystoids (oil liponecrotic pseudosysts) or fat necrosis up to 12 mm in diameter, which did not correlate with the clinical examination. The thickness of soft tissue of the breast was gradually increasing between individual sessions. Postoperative echography at least 6 months after the final session of lipomodelling showed the same benign findings of homogenous tissue with several isolated zones of liponecrosis BI-RADS 1–2 as it is described above (Fig. 1).
Case 1: 14-year-old patient with Poland’s syndrome
A 14-year-old female patient with Poland’s syndrome grade II on the left side with complete aplasia of the pectoral major muscle and significant breast hypoplasia was treated at our department. Degree of breast asymmetry was enhanced by breast hypertrophy on the right side (Fig. 2). Breast reconstruction was performed with lipomodelling technique only. The aim of the first session was to correct chest wall depression caused by the pectoral muscle aplasia. The breast was reconstructed in a total of 5 lipomodelling sessions. The average volume of transferred fat at one session was 216 ml. Last lipomodelling session was performed in the age of 15 years together with central pedicle mammoplasty of the right breast with reduction of 200g. We evaluated reconstructed breast volume after a second lipomodelling session - the patient was asked to measure breast volume by dipping the breast in a container filled with water. Overall fat resorption was 21% (Table 1). The submammary fold and areolar complex were shifted downwards successfully using fasciotomies. Moderate asymmetry 1 year after the surgery (given by a further growth of the right breast) was corrected by secondary mammoplasty of the right breast (Fig. 3).
Case 2: 17-year-old patient with unilateral tuberous breast
A 17-year-old patient with tuberous breast malformation Type II on the left side and with a ptotic right breast (grade 2) underwent surgery at our department (Fig. 4). Correction of tuberous breast deformity was performed in two lipomodelling sessions (240 and 220 ml of fat) at 3-month interval. Superior pedicle vertical mastopexy with augmentation by fat grafting (70 ml) in décolleté area was performed on the right ptotic breast together with the second lipomodelling session. Overall fat resorption as estimated by the patients was about 30%. Satisfactory breast shape and degree of breast symmetry with minimum scars was achieved and the patients were very satisfied with the result (Fig. 5).
Case 3: 19-year-old patient with bilateral tuberous breast deformity
A 19-year-old patient with severe breast asymmetry caused by bilateral tuberous breast deformity underwent surgical correction in our department. There was Type III tuberous breast malformation on the right and Type II deformity with the hypertrophy of the residual mammary gland on the left (Fig. 6). Correction of tuberous breast on the right was performed in two lipomodelling sessions (440 and 230 ml of fat) at 3-month interval. On the left, tuberous breast deformity was corrected by superior pedicle vertical mastopexy. Satisfactory breast shape and degree of breast symmetry was achieved 3 months postoperatively (Fig. 7). The patient got pregnant soon after. She was not able to breastfeed but there was hypertrophy of the left breast six months after childbirth. Patient presents finally with moderate asymmetry 26 months postoperatively caused by a persistent hypertrophy of the left breast (Fig. 8). Patient is satisfied with the result and she does not wish any other correction in this moment.
Coleman codified and made the technique of autologous fat injection popular 11,12, which is now widely employed in plastic and aesthetic surgery. Delay popularized the technique in plastic, reconstructive and aesthetic surgery of the breast and considerably expanded the indications for lipomodelling technique 13–16. The technique is now well established and the complication rate is very low 10,17–19.
A variety of surgical techniques has been used to correct chest wall and breast deformity in Poland’s syndrome, including tissue expanders, breast implants, custom chest wall implants as well as locoregional or free flap, which may be combined if necessary. Complete breast reconstruction by lipomodelling in Poland’s syndrome was first performed in 12-year-old patient with severe chest wall deformity by Delay in 2001. 5 sessions of lipomodelling were required to obtain satisfactory result 20,21. Due to very good results obtained, Delay proposed this reconstructive option to other 10 patients with Poland’s syndrome until 2011 22. The average age of the patients was 16 years (12–24 years), number of lipomodelling sessions was 2.9 (1–5) with average 255 ml of injected fat. No surgical complication was observed. Until 2013, total breast reconstruction using lipomodelling technique was performed in 23 patients by the same surgeon 10. Pinsolle and colleagues presented case series of 7 patients in which fat grafting was used more as a complementary technique to other reconstructive techniques 23. Derder and colleagues documented 2 cases of total breast reconstruction using lipomodelling technique in 17- and 19-year-old patients with satisfactory results 1.
A range of surgical techniques has been used to correct breast shape and volume in tuberous breast, including a combination of skin plasty and mammary gland remodeling, as well as prostheses and locoregional flaps. Among them, lipomodelling has been shown as advanced minimally invasive technique popularized by Delay and Coleman 10,12,14,17. Delay demonstrated in series of 31 patients that lipomodelling is reliable and safe technique of tuberous breast correction with excellent long lasting natural results. Asingle session was required in 45% of the patients with mean transfer volume of 158 ml (50–253 ml), the second session was needed in 55% of the patients with mean transfer volume of 226 ml (100–316 ml). No complications were observed postoperatively and 6 months later ultrasound examination did not reveal any anomalies other then oil cysts 16. Satisfactory results of tuberous breast correction were documented also by Derder (series of 3 patients) 1 and by Klit (in series of 8 patients) 24.
We believe that fundamental principle of lipomodelling technique, which prevents the formation of fat necrosis, is to respect the capacity of recipient tissue for fat graft. Fat graft must be surrounded by vascularized tissue. Therefore, we consider the initial volume of recipient soft tissues to be essential criteria determining the capacity of recipient tissues. In hypoplastic breast anomalies, we proposed to transfer lower volumes during initial lipomodelling session, especially in correction of Poland’s syndrome deformities with hypoplasia or aplasia of the pectoral muscle. Nevertheless, the mean transfer volumes in our case series was 216 ml (187–245 ml) for the correction of Poland’s syndrome and 283 ml (220–440 ml) for the correction of tuberous breast, which were much higher in comparison with Delay`s studies 16,22. No surgical complication was observed postoperatively and ultrasound examination 6 months later did not reveal any abnormalities other then oil cysts in our case series.
The key to achieve the desirable results is to use advanced modeling elements, the most important of which are multiple fasciotomies 25 that is well documented in our case series. In both malformations, the submammary fold was moved at least 2–3 cm downwards (see Figures 2–8). Moreover, the lower part of the breast was sculptured and the areolar herniation was significantly improved in the patients with tuberous breast (see Figures 4–8) and on the other hand in Poland’s syndrome, the areolar complex was moved 3–4 cm downwards and laterally successfully (see Figures 2 and 3).
Main advantages of lipomodelling technique are accentuated in young patients with hypoplastic breast malformation: 1) minimal invasiveness with aesthetic benefit in donor site, 2) minimal extent of the scars on the breast, 3) short recovery time, 4) implant free procedure with no associated risk of infection, extrusion, rupture, capsular contracture and recently suggested association with anaplastic large-cell lymphoma, and no needs of implant exchanging in the future.
We believe that lipomodelling allows for the breast correction to begin in early adolescence because further growth and development of the unaffected breast may be effectively corrected by subsequent session of lipomodelling – autologous and minimally invasive procedure. Furthermore, these young patients can considerably appreciate even partial improvement of their asymmetry after the first session(s) of lipomodelling. More difficult is the timing of possible mastopexy or breast reduction of the contralateral breast if it is required. If accepted by the patient, we recommend performing this surgery from the age of 18 years, when the breast volume is more stable. On the other hand, secondary mammoplasty is not associated with additional anesthesia, if the primary mammoplasty is performed in one session with the final session of lipomodelling.
Lipomodelling is advanced and minimally invasive technique for the correction of congenital hypoplastic breast malformation without need of a silicone implant. In our case series, we confirmed safety of this therapeutic approach. No surgical complications were observed and ultrasound examination within 6 months postoperative did not reveal any abnormalities other then oil cysts in our case series. Submammary fold was moved downwards, the lower part of the breast and areolar herniation were corrected in tuberous breast and finally areolar complex was effectively shifted downwards and laterally in Poland’s syndrome. Lipomodelling allows breast correction to begin in early adolescence because further growth of the unaffected breast may be effectively corrected by subsequent session of lipomodelling. This technique appears to change the overall approach to the management of hypoplastic breast and chest wall malformations.
Declaration of interest: The authors report no conflict of interest. The authors alone are responsible for the content and writing of this article.
Libor Streit, M.D.
Department of Plastic and Aesthetic Surgery
St. Anne’s University Hospital
Berkova 34, 612 00 Brno,
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