SEBASTIEN GARSON M.D
This fact sheet was developed under the aegis of the French Society of Plastic Reconstructive and Aesthetic Surgery (SOF.CPRE) as an addition to your initial consultation, to try to answer all the questions you can ask yourself if you plan to use surgery baldness. The purpose of this document is to provide you with all the necessary and essential elements of information to help you make your decision with full knowledge of the facts. Also you is it advisable to read with the greatest attention.
• DEFINITION OBJECTIVES AND PRINCIPLES
Breast hypoplasia is defined by breasts of insufficient volume in relation to the patient's morphology. It can exist from the outset (small breasts since puberty) or can appear secondarily a hypotrophy, following a significant weight loss or pregnancy. Hypotrophy may be isolated or associated with ptosis (i.e. sagging breast).
The treatment of breast hypoplasia most often consists of correcting the breast volume that is considered insufficient by placing implants (prostheses) behind the mammary gland or behind the pectoralis major muscle. In some cases, this procedure may be combined with skin re-draping (ptosis treatment).
In some cases, it is now possible to increase or restore the volume of the breast by fat transfer.
This technique was initially developed in breast reconstructive surgery, where it has made considerable progress.
It is derived from the technique of fat transfer at the level of the face, which is also called lipostructure or lipofilling or lipomodelling.
As a result of the experience gained in breast reconstructive surgery, the technique has gradually been codified and improved to become a technique in its own right.
Breast fat transfer had indeed been proposed about twenty years ago, but had not been widely disseminated because, on the one hand, technical and conceptual elements were missing and, on the other hand, some people had expressed doubts about the possibilities of monitoring the breast after fat transfer.
The technique of fat transfer at breast level is currently a recognized technique of great effectiveness.
These sometimes major physical alterations, as well as the psychological suffering induced, give a therapeutic purpose to this restorative surgical act.
If they exist, the conditions of coverage by the Health Insurance will be specified by your surgeon.
In order to be practiced in a way that conforms to the proven data of science, it must be carried out in a surgical environment, by a plastic surgeon. The practice of this technique outside the previously defined surgical setting is considered dangerous for patients.
Although it is now clearly established that, as in all breast surgery, whether aesthetic or not (removal of benign or malignant tumours, breast reduction surgery, breast augmentation plastic surgery, etc.), the use of this technique is dangerous for the patient, it is not recommended that it be performed in a surgical setting. ) radiological calcifications may appear (related to tissue healing), these calcifications (macro and microcalcifications) are different from those observed in breast cancer, and do not pose diagnostic problems for experienced radiologists.
In addition, modern fat transfer techniques allow a harmonious distribution of adipocyte grafts, making the risk of oily cyst formation or poor graft setting (cytosteatonecrosis) more limited.
These sometimes major physical alterations, as well as the psychic suffering induced, give a therapeutic purpose to this restorative surgical act.
Currently, it can be considered that a lipomodelling of the breast, done according to the rules of the art by a plastic surgeon experienced in this field, does not cause any particular diagnostic difficulty for a radiologist experienced in breast imaging.
To date, there is no evidence to suggest that fat transfer could promote the development of breast cancer. However, it will not prevent breast cancer if it does occur. Patients have their own risk of developing breast cancer, depending on their age, family history and breast density, among other factors. She must also understand that all precautions must be taken to limit the risk of coincidence between the occurrence of cancer and lipomodelling (strict preoperative check-up by a radiologist specialising in breast imaging; strict check-up at 1 year, then repeated at 2 or even 3 years). With this in mind, the patient requesting breast lipomodelling undertakes to have the preoperative breast imaging check-up (mammography, ultrasound) performed and above all undertakes to have the reference examinations (mammography, ultrasound) performed at 1 year, then according to the recommendations of the specialist radiologist.
It must be stressed that this technique cannot be used for all indications of breast augmentation surgery. Implants remain a part of the therapeutic arsenal. It is also possible to combine the two techniques in the form of a composite augmentation.
These are procedures with different objectives:
Breast augmentation with implants is suitable for patients who want a significant increase in breast volume and a radical transformation of their breasts.
Aesthetic lipomodelling of the breasts allows only a moderate increase and is more suitable for patients who want to return to a "previous state" (after weight loss, pregnancy, breastfeeding) and/or want a more "natural" solution.
"natural", with no prosthetic foreign body. Furthermore, this technique is only possible if the patient has a sufficient fat-donating site.
On the other hand, it should be remembered that when the operation is a purely aesthetic surgery, it is not covered by health insurance.
In breast repair surgery, on the contrary, health insurance is involved in the management of malformations or breast deformities, which may be innate (genetic or familial), induced by trauma (burns, accidents), or occur without currently known explanation.
A distinction is made between malformations or deformities with or without a mammary gland, with or without areola-mamelon plaque, with or without associated thoracic malformations.
Fat transfers can contribute in many clinical situations:
Poland Syndrome: A congenital syndrome, characterized by aplasia or hypoplasia of the mammary gland, with small, sometimes rudimentary nipple-areolar plaque, often associated with an absence or deficit of the pectoralis major muscle, and associated costal and thoracic malformations. This syndrome may be accompanied by malformations of the homolateral upper limb (particularly in the fingers, with syndactyly type). The skin is frequently thin. There is a three-stage classification according to severity.
Breast aplasia and breast hypoplasia: the structures of the breast have not developed well, but exist in a rudimentary state, or have undergone insufficient development. All intermediate forms can be seen.
Lipomodelling is particularly interesting for unilateral hypoplasia.
Tuberous breasts: appear at the time of puberty, during breast growth, which does not go well. This malformation is due to a defect in the breast base, and predominates in the lower part of the breast.
The breast 'capotes' above the thorax because the lower segment of the breast is short. This malformation can be familial in character, and is often asymmetrical in shape and volume. Three stages can also be distinguished depending on the severity of the deformity. Lipomodelling provides an important complement in terms of volume and shape improvement. It is most often combined with another surgical procedure to obtain the right result.
Pectus excavatum: is a thoracic malformation that causes a hollow in the thoracic wall, medial or lateralized. It can be treated with different solutions: silicone prosthesis, or lipomodelling if there is enough fatty tissue available. In some cases, it may be appropriate to combine the two techniques.
Deformations induced in childhood (by burns, accidents, after radiation, or after surgery): for these rare cases, the treatment is specific to each situation, but fat transfers are very interesting because they bring volume, flexibility, and decrease local fibrosis.
The treatment of thoraco mammary malformations and deformities is variable, as most cases are special cases. Some patients may benefit from conventional plastic surgery techniques (breast reshaping, breast prosthesis, liposuction) especially when there is enough skin or volume. In many cases, fat transfer is an important step forward. It can then be used alone, or most often in combination with other techniques.
This technique can only respond to precise indications, and requires that the patient has sufficient 'adipose capital' to allow fat removal under good conditions. Very thin patients are therefore not good candidates for this technique.
It can meet the expectations of a patient who wants a moderate increase in breast volume or who wishes to regain a more harmonious curve on an "empty" breast (slimming, pregnancy, breastfeeding).
This technique has two major advantages:
it allows an increase in breast volume, certainly moderate, but completely natural, without foreign bodies, and does not give the appearance of an artificial breast.
it allows to treat at the same time possible localized fat overloads that are disharmonious (fat sampling sites).
As before any breast surgery, a clinical examination of the mammary gland must be carried out in order to detect a pathological process.
Similarly, it is necessary to have specific complementary breast examinations (mammography and breast ultrasound, or MRI if necessary) to detect any suspicious abnormalities. Any suspicious abnormality detected by these examinations will require the additional opinion of a qualified senologist, and will temporarily contraindicate breast lipomodelling surgery.
If all these precautions are taken, the procedure can be considered serenely and without ulterior motives..
• BEFORE THE OPERATION
The therapeutic plan is developed jointly by the patient and the surgeon.
In particular, the expected aesthetic benefit, the limits of the technique in terms of volume gain, the advantages, disadvantages and contraindications will be discussed.
A meticulous clinical and photographic study is carried out.
A precise radiological assessment is carried out by a radiologist specialized in breast imaging who is familiar with the radiological characteristics of breasts that have benefited from lipomodelling. If possible, it will be this same radiologist who will carry out the reference examinations that it is necessary to have carried out at a distance from the operation.
The anaesthetist will be seen in consultation at least 48 hours before the operation.
No medication containing aspirin or an anti-flammatory must be taken during the 15 days preceding the operation.).
THE TOBACCO ISSUE
The scientific evidence is currently unanimous about the harmful effects of smoking in the weeks surrounding surgery. These effects are multiple and can lead to major scarring complications, surgical failures and infection of implantable devices (e.g. breast implants).
For procedures involving skin detachment such as abdominoplasty, breast surgery or cervicofacial lifting, smoking can also cause serious skin complications. In addition to the risks directly related to the surgical procedure, smoking can be responsible for respiratory or cardiac complications during anesthesia.
With this in mind, the community of plastic surgeons agrees on a request for complete cessation of smoking at least one month before surgery and then until healing (usually 15 days after surgery). The electronic cigarette should be considered in the same way.
If you smoke, talk to your surgeon and your anesthesiologist. A prescription for nicotine substitute may be offered. You can also get help from Tabac-lnfo-Service (3989) to refer you to a smoking cessation or to be helped by a tobaccologist.
On the day of the operation, if there is any doubt, you may be asked to take a urine nicotine test and if positive, the operation may be cancelled by the surgeon.
• TYPE OF ANESTHESIA AND CONDITIONS OF INTERVENTION
Aesthetic breast lipomodelling is usually performed under general anesthesia because several anatomical sites are involved in the same operation:
the areas to be removed (buttocks, hips, abdomen or saddlebags, inner side of the knees)
This surgery requires a short hospital stay of about 12 to 24 hours.
Each surgeon adopts a technique that is specific to him and that he adapts to each case to obtain the best results. However, there are some common basic principles:
The surgeon begins by precisely identifying the areas where the fat is to be removed and the recipient sites. The choice of these harvesting areas depends on the areas of excess fat and the wishes of the patient, because this harvesting allows an appreciable improvement of the areas under consideration, by performing a real liposuction of excess fat. The choice of collection sites also depends on the amount of fat deemed necessary and the collection sites available.
The removal of the fat tissue is carried out atraumatically, through small incisions hidden in the natural folds, using a fine suction cannula (a technique derived from that of liposuction), followed by centrifugation, in order to separate the intact fat cells to be grafted from the elements that cannot be grafted (serosities, oil).
The transfer of the fat tissue is done through 1 to 2 mm incisions using micro-cannulas. Microparticles of fat are transferred in different planes (from the plane of the ribs to the skin), along many independent paths (creating a true three-dimensional network), in order to increase the contact surface between the implanted cells and the recipient tissues, which will best ensure the survival of the grafted fat cells and thus the
"taking the graft."
As it is a real live cell transplant (with an estimated uptake of 60 to 70% depending on the patient), the transplanted cells will remain alive. Aesthetic lipomodelling is therefore a definitive technique since the fat cells grafted in this way will live as long as the tissues around them. On the other hand, the evolution of these fat cells depends on the adiposity of the patient (if the patient becomes thinner, the volume brought in will decrease).
The duration of the procedure depends on the number of donor sites, the amount of fat to be transferred, and a possible change in position. It can vary from 1 hour to 4 hours depending on the case.
AFTER THE INTERVENTION: THE OPERATING SUITES
After the operation, the pain is generally moderate, but can be temporarily quite severe in the area of the puncture site. Tissue swelling (oedema) at the puncture sites and in the breasts occurs during the first 48 hours after the operation and usually disappears within 1 to 3 months. Bruises (bruises) appear in the first few hours at the fat removal sites and will disappear within 10 to 20 days after the operation.
Some fatigue may be felt for one to two weeks, especially in the case of fat removal and major liposuction.
It is advisable not to expose the operated areas to the sun or UV rays for at least 4 weeks, which would imply the risk of skin pigmentation. After resorption of the phenomena of oedema and ecchymosis, the result begins to appear within 1 month after the operation, but the result close to the final result requires 3 to 6 months.
• THE RESULT
It is assessed within 3 to 6 months after the intervention. It is most often satisfactory, whenever the indication and the technique have been correct: the breasts operated on generally present a larger volume and a more harmonious curvature. The silhouette is also improved thanks to liposuction.
sampling areas (hips, abdomen, saddlebags, knees).
A second lipomodelling session is possible a few months later if necessary (and if possible given the fat donor areas), in order to further increase the volume of the breasts, or to improve their shape. This second intervention involves constraints and costs comparable to those of the first session.
Since the fat cell transplant is a success, we have seen that these cells remain alive as long as the tissues in which they were transplanted remain alive. However, the normal aging of the breasts is not interrupted and the appearance of the breasts will naturally change over time.
• FAULTS OF THE RESULT
The loss of breast volume following weight loss should also be emphasized.
We have seen that, in most cases, a breast lipomodeling correctly indicated and carried out is a real service to patients, with a satisfactory result and in accordance with what was expected. In some cases, a second lipomodeling session is necessary under general anesthesia to obtain the adequate result. The number of sessions is not limited, except by common sense, and the amount of fat available can be harvested.
In a few cases, localized imperfections may be observed (without them constituting real complications): localized hypo-correction, asymmetry in the management of the asymmetry, irregularities. They are then accessible to a complementary treatment: lipomodelling under simple local anaesthesia, from the 6th month postoperatively.
• POSSIBLE COMPLICATIONS
Breast lipomodelling, although performed for essentially aesthetic reasons, is nonetheless a true surgical procedure, which implies the risks inherent in any surgical procedure, however minimal it may be.
In particular, this procedure is subject to the risks associated with living tissue, whose reactions are never entirely predictable.
A distinction must be made between complications related to anaesthesia and those related to the surgical procedure.
As far as anaesthesia is concerned, during the consultation, the anaesthetist will himself inform the patient of the anaesthetic risks. It is important to know that anaesthesia induces unpredictable reactions in the organism, which are more or less easy to control: the fact of having recourse to a perfectly competent anaesthetist, working in a truly surgical context, means that the risks incurred are
have become statistically almost negligible. Indeed, it should be noted that techniques, anaesthetic products and monitoring methods have made immense progress over the last twenty years, offering optimal safety, especially when the operation is carried out outside the emergency room and in a healthy person.
As far as the surgical procedure is concerned: by choosing a qualified and competent Plastic Surgeon, trained for this type of intervention, you limit these risks as much as possible, without however completely eliminating them.
In fact, the real complications are rare after a quality lipomodelling: a great rigour in the indication and in the surgical realization is required, to ensure in practice, an effective and real prevention.
Infection is normally prevented by prescribing an intraoperative antibiotic treatment. In case of occurrence (rare), it will be treated by antibiotic therapy, ice, and by removing the point located opposite the inflamed area. The resolution is then done in about ten days, usually without any significant consequence on the final result.
In total there should not overstate the risks, but just be aware that surgery, even seemingly simple, still a small share of hazards. The use of a qualified Plastic Surgeon ensures that it has the training and knowledge required to avoid these complications, or effectively treat if jurisdiction.
These are the pieces of information that we wanted to bring you in addition to the consultation. We recommend that you keep this document, read it again after the consultation and reflect "a clear head." This reflection may raise new questions for which you wait for additional information. We are available to talk during the next consultation, or by phone, or even on the day of surgery when we meet in any way before anesthesia.
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