الفهرس 
INTRODUCTIONOnly 14 pages are availabe for public view
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Abstract
The esthetic sequelae of surgical treatment of breast cancer are difficult to treat. Lipomodeling offers a new treatment option, consisting of transferring to the deformed breast fatty tissue that has been meticulously harvested and prepared. We consider lipomodelling a technique whose concept is simple but that requires a learning curve to avoid the formation of fat necrosis. It yields very good results regarding contour and suppleness of the breast while avoiding the need to use an implant or to sacrifice muscle. Stable results are obtained after the normal fat resorption in the early months, if the patient maintains a constant weight. Radiological images of calcifications or fat necrosis are a frequent occurrence after lipomodelling and are similar to those induced by any type of breast surgery, notably the initial conservative treatment.
Although this technique appears to represent a considerable advance in the therapeutic armamentarium for moderate sequelae of conservative treatment, we consider it as only part of a multidisciplinary approach. The radiologist who carries out preoperative investigation must be in agreement with the principle of the procedure, as must the cancerologist following the patient for her cancer. The opinion of all those involved must be respected. Such an approach and sharing of responsibility allow all those involved to work together to limit the potential medicolegal complexities in the event of further progression of cancer.
The aim of this work was to evaluate the efficacy, complications and esthetic outcomes of delayed lipomodelling after mastectomy and breast conservative surgery and to determine the oncological safety of lipomodelling on experimental level.
As a pre-clinical study, the experimental laboratory results were obtained prior to the start of the human research: Step I- Breast cancer inoculation:
• 50 Balb C white female mice, at 3 months of age, were subcutaneously injected underneath the second left nipple by 0.1 ml of Ehrlich Ascites tumor cells (EAC) containing approximately 15-20 X 106 cells.
• The mean time of tumor appearance after EAC injection was 10.75 days ranging from 7-14 days.
• 5 mice (10%) didn’t develop any tumor after injection of EAC and 5 mice (10%)
developed advanced tumor attached to chest wall and were excluded from the study.
• All mastectomy specimens of 40 mice (80%) showed malignant transformation in breast tissues excised.
Step II- Fat graft and analysis:
• All mastectomized mice (34 mice) 68% were divided into 2 equal groups:
group A: 17 mice (34%) have undergone autologous fat graft transplantation under
the scar of mastectomy.
group B: 17 mice (34%) after mastectomy without fat graft transplantation for detection of local recurrence.
• No local recurrence or rejection after fat graft transplantation was clinically detected over 3 months. Infection occurred in 2 mice (11%) and graft survival clinically observed revealed decrease in size by 50% over 3 months in 7 mice (41.1%).
• Histopathological examination of fat grafts (of 17 mice) excised after 3 months of fat injection revealed no malignancy in all specimens.
The Clinical Human Research included:
Sixty-five sessions were carried out in 50 patients who had undergone delayed
lipomodelling after breast cancer surgery and at least 6 months after completion of radiotherapy. They were admitted to the surgical department of the Medical Research Institute Hospital, University of Alexandria in the period from September 2013 to June 2015 and all cases followed up for at least 6 months.
Full laboratory and radiological investigations were performed in all patients.
Preoperative markings of both donor and recipient areas was done in standing position.
The technique used was Coleman’s technique consisting of:
1. Harvesting by a blunt-tipped liposuction cannula (2mm) with slight negative pressure of 50cc Luer Lock syringe to allow fat harvesting.
2. Processing by centrifuge of harvested fat under aseptic technique at 3000 rpm for 3-4 min. The fat is separated into 3 layers: top oily layer, middle layer of purified fat and bottom layer of blood residues.
3. Lipoinjection of the cellular component (middle layer) transferred to a 1 or 3 cc Luer-Lock syringe and prepared for injection by blunt-tipped small caliber infiltration cannula (1-2 mm).
The findings can be summarized into:
• The mean age of the studied patients was 39.94 years ranging from 17 to 61 years.
• The mean BMI was 29.42, the maximum BMI was 44 and the minimum was 18.
• As the patients were randomly allocated, they were finally grouped in 4 categories according to the original operation:
1. group I: BCS (Breast Conservative Surgery) = 10 cases
2. group II: Mastectomy = 9 cases
3. group III: Mastectomy + Flap = 16 cases
4. group IV: Mastectomy + Prosthesis = 15 cases
• The type of primary oncological resection was: 30% (15 cases) modified radical mastectomy, 28% (14 cases) nipple sparing mastectomy, 24% (12 cases) skin sparing mastectomy and 20% (10 cases) breast conservative surgery.
• The pathology of the primary tumor was: invasive ductal carcinoma grade II in 40 cases (80%), invasive ductal carcinoma grade III in 9 cases (18%) and invasive lobular carcinoma grade II in 1 case (2%).
• The stage was: 50 % of the cases (25 case) were: stage IIB, 26% (13 cases) stage IIA,12% (6 cases) stage IIIA, 8% (4 cases) stage I and 4% (2 cases) stage IIIB.
• The mean time from oncologic surgery to lipofillling was: 19.97 ± 12.74 months; the
shortest period was 3 months, while the longest one was 102 months.
•88% (44 cases) have taken adjuvant radiotherapy, while 12% (6 cases) have not.
•The mean time after last radiotherapy setting prior to lipofillling was 14.26 ± 13.04
months; the shortest period was 6 months, while the longest one was 96 months.
•Oncoplastic techniques were used in 9 cases (18%) for breast conservative surgery in
group I prior to lipomodelling.
• 62% (31 cases) only have undergone previous breast reconstruction; 52% (26 cases)
with immediate reconstruction, while 10% (5 cases) with delayed reconstruction.
• Type of breast reconstruction was: 14% (7 cases) TRAM flap, 18% (9 cases) LD flap,24% (12 cases) Prosthesis, 6% (3 cases) LD flap + prosthesis.
• Multiple indications for lipomodelling were needed even for the same session:
contour remodeling in 34 sessions (52.3%), symmetrization in 27 sessions (41.5%),
post-surgical defect correction in 18 sessions (27.7%), mask implant rippling in 4 sessions (6.2%), complete breast reconstruction by lipofilling in 20 sessions (30.8%), complete breast reconstruction by prosthesis and lipofilling in 21 sessions (32.3%).
• Lipomodelling were performed under general anesthesia in 56 sessions (86.2%) and
under local anesthesia in 9 sessions (13.8%) mainly for cases of group I (5 sessions).
• Most patients needed only one session of lipofilling (41 cases (82%)), two sessions
were needed only in 6 cases (12%), while three sessions were needed in 3 cases (6%).
• The mean interval between sessions was 4.42 ± 2.35 months; the minimal interval was
3 months, while the maximal interval was 10 months.
• The mean duration of operation was 128.54 ± 46.63 minutes; the shortest period was
30 minutes in group I, while the longest one was 240 minutes in group IV.
• The donor site was the abdomen in 31 sessions (47.7%), the thigh in 14 sessions
(21.5%) and both thigh & abdomen in 20 sessions (30.8%).
• After centrifugation of fat, the amount of pure fat separated is less than the amount of
fat harvested; in session 1 (51 sessions) the mean amount of fat harvested was 522.25±255.74 ml and the mean amount of pure fat injected was 182.84±88.74 ml
(34.8% of total), in session 2 (10 sessions) the mean amount of fat harvested was 497.00±318.82 ml and the mean amount of pure fat injected was 184.50±140.29 ml
(37% of total), in session 3 (4 sessions) the mean amount of fat harvested was 300.0 ±
244.95 ml and the mean amount of pure fat injected was 121.25 ± 121.27 ml (40.3% of
total).
• The mean of total amount of fat harvested was 504.69± 266.60 ml, while the mean of
total amount of pure fat injected was 179.31 ± 99.17 ml for all sessions.
• There was a statistically significant correlation in different groups between the amounts
of fat harvested (P= 0.015) and the amount of pure fat injected (P= 0.010).
•There was a statistically significant correlation between the amount of pure fat injected
and volume excised in BCS (p= 0.001).
•9 cases (18%) had definitive prosthesis with lipofilling mainly of group II (4 cases)
and group IV (5 cases).
•Prosthesis was exchanged in 7 cases (41.2%) and removed in 8 cases (47.1%).
• Contralateral procedure was done in 19 cases (38%): mastopexy in 9 cases (18%),
reduction mammoplasty in 5 cases (10%), augmentation by prosthesis in 3 cases (6%) and lipofilling in 2 cases (4%).
• Nipple Areola Complex (NAC) Reconstruction + Tattoo was done in 19 cases (38%),
not done in 12 cases (24%) and not needed in 19 cases (38%).
• The timing of NAC Reconstruction was with lipofilling in 10 cases (52.6%), with last
session of lipofilling (if staged) in 5 cases (26.3%) and after lipofilling by 2 months in 1
case (5.3%), after 4 months in 1 case (5.3%) and after 6 months in 2 cases (10.5%).
•The mean timing of NAC Reconstruction was 4.50 ± 1.92 months.
•The mean follow up duration was 15.38 ± 5.37 months; the minimum period was 6
months and the maximum period was 24 months.
•In 25 sessions (38.5%) lipomodelling was needed to be repeated, but the patient
compliance was variable: refusal in 4 sessions (6.2%), non-compliance in 5 sessions
(7.7%), acceptance in 16 sessions (24.6%) and no need in 40 sessions (61.5%).
•The donor complications were: ecchymosis after 61 sessions(93.8%), altered
sensation after 7 sessions (10.8%) and hematoma after 2 sessions (3.1%).
•The recipient complications were: fat necrosis after 15 sessions (23.1%), ecchymosis
after 4 sessions (6.2%), seroma after 2 sessions (3.1 %), infection after 1 session (1.5%)
and local recurrence after 1 session (1.5%).
•The mean absorption rate subjectively measured after 6 months was 36.30 ± 10.87%
with minimum 20% and maximum 60%.
• Radiological findings were: microcalcifications after 3 sessions (4.6%), oil cysts after 6
sessions (9.2%) and fat necrosis after 15 sessions (23.1%).
• Local recurrence, with the same histologic subtype of the primary tumor, occurred in 1
case (2%) which performed 2 sessions of lipofilling (10 months inbetween) post MRM and local recurrence occurred as small nodule after 5 months of the second session of lipofilling and 27 months after MRM.
•Distant metastasis (liver and suprarenal gland) occurred in 1 case (2%) 8 months after
lipofilling and 18 months after NSM.
•The mean time from lipomodelling to appearance of fat necrosis was 4.27±1.16
months with minimum of 3 months after 5 sessions (33.3%) and maximum of 6 months
after 3 sessions (20%).
•Fat necrosis was excised after its appearance in 12 sessions (18.5%).
•There was a statistically significant correlation between excision of fat necrosis and fat
necrosis. (P value <0.001).
•Factors affecting occurrence of fat necrosis:
1. Surgical technique
2. Tissue quality
3. Duration of operation
4. Amount of pure fat injected in ml per session
5. History of post-operative radiotherapy
The psychological impact of surgery in breast cancer patients is multi-factorial; the cosmetic result and body image being as important as the fear of cancer recurrence. Better cosmetic results produce a better psychological outcome.
Our esthetic evaluation was:
• Patients’ satisfaction: by a questionnaire full filled by all patients, 16 patients (32%)
were very satisfied, 20 patients (40%) were satisfied, 9 patients (18%) were unsatisfied
and 5 patients (10%) were very unsatisfied.
• Doctor satisfaction were evaluated by two different surgeons by clinical examination
and from the photographic records of each patient before and after the procedure. The
results were: excellent in 13 patients (26%), good in 22 patients (44%), fair in 9 patients
(18%) and insufficient in 6 patients (12%).
• There was a statistically significant correlation between patients’ satisfaction and doctor
satisfaction (P value <0.001).
• Using the BCCT.core program the esthetic results were: excellent in 5 patients (10%),
good in 23 patients (46%), fair in 18 patients (36%) and poor in 4 patients (8%). There
was a statistically significant correlation between the esthetic results in different groups
of patients (P value = 0.007).