Total Breast Reconstruction with Autologous Fat Transfer (AFT) and Expansion Reversal (ER): Experience with 2000 AFT-ER Breasts.

Roger K Khouri, MD; Raul A Cortes, MD; Daniel Calva-Cerquiera, MD

Introduction: Miami Breast Center

Autologous reconstructions provide better long-term patient

satisfaction but are in-patient invasive procedures with morbidities

and complications. AFT alone reconstructions are limited because

fat is not an expander. Pre-expansion of the mastectomy followed

by AFT to the tissue laxity created by removal of the expander is a

Reverse Expansion (RE) that solves this limitation.

Materials & Method:

For immediate reconstructions, we insert subpectoral expanders and

graft 150-200ml as fat ribbons teased in-between the exposed

muscle fibers. After adequate post-operative expansion, we remove

the expander, graft the laxity with 250-350ml of fat, and preserve

the breast mound by inserting an implant half the expander size. To

convert the implant reconstructed breasts to autologous fat, we

remove the implant, replace it with a 50% smaller one and graft the

loosened tissues. In both situations we repeat the procedure every

three months till the patient is implant free.

Results:

We reviewed our past 2000 consecutive AFT-ER out-patient breasts

reconstructions. Non-radiated mastectomies required 3.2 sessions.

At each session, the expanded breast volume remained constant as

the intervening mastectomy tissue thickness doubled while the

implant volume halved. Radiated breasts took 5.8 sessions, with less

grafting per session and less than halving implant size. Patient

satisfaction was very high, especially for the previously implant

reconstructed patients converted to autologous fat. Complications

were minimal, more frequent in the radiated breasts and mostly due

to over-grafting or excessive scar release in patients with previous

complications.

Conclusion:

The AFT-ER procedure is a very satisfying autologous breast

reconstruction alternative. It is safe, has no donor site defect, and a

liposuction body contour bonus. The multiple procedures are outpatient

and minimally invasive.

2 cm 5.2 cm

Dome Volume =

2/3π (r+2)3 - 2/3π r3 = 457 ml

Disk Volume = 2πr2 = 157 ml

Remove Implant V. Fibers Prevent Ballooning

290 ml Implant

Tissue

Fat Graft

Implants Expand Tissue,

Removal Makes Room for More

Grafts

Room for 300 ml Fat Graft

Implant Removal is Expansion Reversal

Incision Outside Breast Finger Inside Cavity

Controls Cannula & Prevents Intra-Cavity Grafting

Tease Vertical Fibers & Disperse MicroGrafts

Multiple Puncture Wounds for Cannula Entry Sites

Implant to Fat Conversion (Expans. Revers.)

Inject in Planes Between Skin & Capsule

Lipografter®

Practical,

One Handed,

Disperse Fine

Droplets with

Small Syringe.

Percutaneous Needle Release of Vertical Fibers

to Mesh-Thicken Recipient Plane

(Rigottomies) while avoid making cavities

Bilateral Immediate AFTER Reconstruction

Immediate 400ml AFT + 300ml Sub Pect. Expander

Postop1 400ml AFT + Exchange 300ml with 170ml Implant

Postop#2 400ml AFT + Remove 170ml Implant

1y AFTER No Implant, All Autologous Fat MRI

Downsize Gradually!

Avoid Wrinkles

AFTER - Downsize 800ml to 360ml Implant + 300 ml AFT

800 ml Implant Out

1 y. Post AFTER 650ml Implants to AFT/ 3 Ops 1 y. Post AFTER 4800ml Implants to AFT/ 3 Ops

NO TOUCH

Buttock

Augmentation

Bilateral Delayed AFTER Reconstruction

Post op1 Replaced 550ml Implants with 250ml + AFT

Post op2 Replaced 250ml Implants with 130ml + AFT

1 y Post op3 AFTER: No Implant, All Autologous Fat

Donor Sites