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Reply: Outcomes of Prosthetic Reconstruction of Irradiated and Nonirradiated Breasts with Fat Grafting

2017; Lippincott Williams & Wilkins; Volume: 140; Issue: 3 Linguagem: Inglês

10.1097/prs.0000000000003616

1529-4242

Ewa Komorowska–Timek, Zaahir Turfe, Alan T. Davis,

Body Contouring and Surgery

Sir: We would like to thank the authors for their kind comments regarding our recent article, “Outcomes of Prosthetic Reconstruction of Irradiated and Nonirradiated Breasts with Fat Grafting.”1 It is well known that radiation therapy in breast cancer adds complexity to reconstructive efforts. To avoid transfer of traditionally used vascularized tissues, fat grafting, a modality with less morbidity, has been successfully applied to “mend” the radiation-damaged skin envelope.2,3 Similar to the authors, we now routinely use an intermediate stage of fat grafting over an irradiated tissue expander 3 to 4 months before the final implant exchange. From a technical perspective, depositing fat globules in the interface between the taut irradiated skin and implant capsule, or sometimes the implant itself, can be performed in an intuitive and rather straightforward manner using hydrodissection principles. However, to avoid lumpiness or dimpling in the breast construct with this approach, one needs to distribute the fat graft evenly by percutaneously taking down any adhesions between the skin and capsule. Uniform enhancement of the periprosthetic skin envelope by fat allows safer nipple creation and leads to improved aesthetics and likely increases longevity of the reconstruction.1 As noted previously by the authors, fat transfer into irradiated chest wall decreases or even eliminates postmastectomy pain.4 Lessening of breast and chest wall pain after fat grafting can be attributed to reduction of scarring and/or improved bulk and pliability of the soft tissues (Fig. 1). (See Video, Supplemental Digital Content 1, which shows the patient 3 months after the first transfer of 235 ml of fat graft into the left chest wall with complete pain resolution and considerably improved pliability and bulk of chest tissues, https://links.lww.com/PRS/C332.) It can also serve as an introductory step to subsequent fat transfers in selected patients. Serial fat grafting performed at 6- to 9-month intervals allows gradual creation of the breast mound, which can be left as a fully autologous construct or augmented with a prosthesis (Fig. 2).Fig. 1.: A 49-year-old physical therapist who reported pain and decreased range of motion after left mastectomy and radiation therapy desired to have left breast reconstruction. On examination, the left chest wall skin was leathery and adherent to the ribs. Because of her physically demanding profession, the patient did not consent to surgery involving violation of muscles.Fig. 2.: The same patient 6 months after prepectoral placement of a 150-ml smooth round silicone gel implant following four sessions of fat grafting of 235, 228, 200, and 350 ml transferred at 6- to 9-month intervals.Video.: Supplemental Digital Content 1 shows the patient 3 months after the first transfer of 235 ml of fat graft into the left chest wall with complete pain resolution and considerably improved pliability and bulk of chest tissues, https://links.lww.com/PRS/C332.In brief, fat grafting of an irradiated mastectomy site appears to consistently help with pain and improve the quality of tissues. “Reclaiming the wastelands” with fat transfer can now facilitate reconstructive approaches that were not considered in the past. PATIENT CONSENT The patient provided written consent for the use of her images. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Ewa Komorowska-Timek, M.D.Advanced Plastic Surgery, Michigan State UniversityCollege of Human Medicine, and Grand Rapids Medical Education PartnersGrand Rapids, Mich. Zaahir Turfe, M.D.Henry Ford Health SystemDepartment of OtolaryngologyDetroit, Mich. Alan T. Davis, Ph.D.Grand Rapids Medical Education Partners, and Department of SurgeryMichigan State UniversityGrand Rapids, Mich.