Lipomodelling Procedure

New Zealand Herald article

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Recent Advances

We have been developing the technique of transferring and lipomodelling in larger volumes for breast surgery.
Improvements continue to occur in all of the areas of the process, including:
  • Selection of cells for transfer
  • Harvesting techniques
  • Cell support mediums outside the body before transfer
  • Cell separation
  • Grafting placement
The outcome is now a very reliable method with more than 80 percent fat retention in most cases and the ability to move the breast two cup sizes in many cases in one sitting.
The method works very well for correction of small breasts, asymmetric breasts, loss of breast tissue after pregnancy.
We are also developing improved methods of breast reconstruction after cancer treatment, avoiding major flaps where possible and, when these are necessary, avoiding the sacrifice of any major muscles.
The main quest is adequate donor tissue availability which is not usually a problem.
Using fat cells in cases of cancer used to cause anxiety about the possiblity of a stimulating effect, but several large studies have established safety beyond all reasonable doubt.
There are some cancer surgeions in the UK deliberately placing new fat around active cancers in order to limit the amount of breast tissue to be removed, particularly skin.
Our own safety data is consistent with the European experience which shows that recurrences of cancer can occur after any reconstructive surgery but after fat grafting is about half the rate that could be expected on current figures.
There is now more emphasis on the bed capacity to place the graft into the breast.
Larger beds mean larger graft volumes and quicker progress is possible. We are now developing additional procedures and reconstructive methods to increase the available size of the bed at an internal scaffold.
The relative lack of post-op problems has been our consistent experience.
 

One Step implant removal, capsule removal and compensatory Lipomodelling to restore size and natural shape

A one step implant removal with Lipo modelling is a significant advance and is in our experience the treatment of choice for the problem implants.

The common difficulty is being unwell and having chronic poor health when everything else that may cause it has been ruled out.

The conventional approach has been to remove implants and any capsule and place fresh ones in. This is based on the belief that the problem is implant tissue reactions.

However, biofilm bacteria are the problem as evidenced by many studies in the research laboratory using special techniques such as scanning electron microscopy, DNA profiling and Ultrasound separation to isolate the bacteria which are not cultured by ordinary methods.

Most surgeons however have not been convinced because the biofilm bacteria are notoriously difficult to isolate and swabs taken  on implant  removal generally results in negative culture reports .

The industry that manufactures the implants have placed their research efforts into improving the implant surface eg Nano texturing in the belief that it would result in less problems .

However this has resulted in a larger surface area for biofilm to become established and the emergence of the Large cell lymphoma tumour related to the chronic inflammation has been the result. Fortunately, this is uncommon with estimated risk of one in 100,000 implants. We don’t really know the true rate however, and it is increasing as it is being looked for.

It is clear that there in a much larger proportion of women with implants that suffer from chronic inflammation and poor health. The exact proportion of the implant population is unknown. With the old implant about 15% but with the newer ones with extra texturing this is unknown and may be higher.

We have  found in all  women who have the above picture that  the Pathological finding following removal  confirm and  support their decision to have them removed and  we disagree strongly with advice that reassures or dismisses symptoms.

Clearly there is a large surface area in cases with bacterial biofilm and toxins that is sufficient cause for the debilitating symptoms which disappear upon removal.

Our approach is to remove the implant and the capsule en bloc. The fluid if any around the implant is sent for cytology, the capsule is also sent for pathological examination of the tissues under the microscope to confirm the scar and inflammatory changes to chronic biofilm.

In addition a portion of the capsule is sent for special process to culture for biofilm which involves tissue maceration, ultrasound and prolonged culture in special mediums under aerobic and anaerobic conditions.

Ordinary swabs are also taken to pick up bacteria that may be free swimming. (Planktonic) 

This results in a very thorough extraction of the information that we need to document.

Once the implants are out and the specimens secured Lipomodelling is then done into the intact breast tissue in front of the old breast implant cavity which restores the lost volume and gives a natural comfortable breast that lasts for the rest of one's life and needs no special long term follow up.

Breast cancer screening can occur normally as fat is a normal component of breast tissue and mammography x rays pass through fat easily.

The Procedure

IMPLANT REMOVAL AND COMPENSATORY LIPO-MODELING

There are three stages of the operation plus tests and three positions on the operation table.

First Stage

First stage of the operation uses lateral positions for fat harvest on one side then turn to the other side. The aim is for 300cc graft or above to fill bed capacity on each side of breast tissue in front of implant as this gives best results.

The harvest is done with smaller instruments and half the pressure of ordinary liposuction to preserve cells. Harvest is taken from areas of excess particularly targeting small cells for grafting.

The fat harvest takes much of the morning to get the required volumes, gravity separated, washed and centrifuged in preparation for transfer back to the body.

The lipo-modeling softens scar from cavity collapse after implant removal, softening the scar reaction following removal of capsules which is usually infiltrating muscle and adherent to chest wall.

Second Stage

The second stage is positioning on back in mild beach chair position and removal of implants and capsules with special lighted retractors with slow detailed separation of the inflamed scar to avoid injury to chest wall and complete removal. This takes between 2 hours and 4 hours if very stuck and adherent.

The fluid around the implant is drawn off and sent for cytology (to rule out Giant Cell Lymphoma) and bacterial cultures are taken. The capsule is sent for histology with some of the capsule  sent  fresh for specialised biofilm culture…

Once the implants are out, grafting can commence as the third stage.

Third Stage

The aim is to fill the available bed of breast tissue to its safe capacity, which involves specialised cannulas attached to 3 ml syringes to deposit a fine slurry of fat cells. Three mls is deposited at each pass into its own individual tunnel to maximise revascularisation and survival. There are hundreds of passes on each side to get the best modeling effect. The bed is full when no further tunnels are available.

This takes an hour or so each side. We aim to get above 300cc graft each side provided that the bed has this capacity as this virtually guarantees that the operation will be completed in one stage.

The bulk of the costs are in theatre and anaesthetic time. Surgery is a smaller part of the costs.  Anaesthesia is usually Total Intravenous or TIVA, combined with copious local anaesthesia for quick recovery.

We have tracked our outcomes using the widely validated breast Q patient self-assessment of results and they compare very favourably with international experience. The results were presented at the recent international plastics conference held recently in Auckland August 2018, where the French also gave their experience with similar results.

The procedure and approach was described by the French surgeons as a completely different paradigm, or way of thinking and working, to achieve the results. I agree with this.

It is certainly possible to be offered simple implant removal, which is relatively quick and inexpensive but would not result in complete capsule removal particularly in the inflamed cases.

Failure to test properly and remove the capsules,  exposes patients to a life time risk of Lymphoma in the French experience.

Typically patients go into theatre at 8.30 am and get out at 4.30 pm for the full three stages.

Whilst removal can be done separately and grafting later it gets a better result to do it straight away as the grafted fat reduces the scar retraction that can occurs after removal of inflamed implants and collapse of the cavity from which the implant has been removed. However, in some cases of rupture and leakage with spread into surrounding tissues a stage approach is better.