SIEF - Simultaneous Implant Exchange with Fat - A New Option in Revision Breast Surgery
During the 1992-2006 moratorium on silicone breast implants, millions of saline implant augmentations were performed. Some of these patients, approaching middle age, no longer desire the convex upper pole appearance often associated with over-filled saline devices or have undergone volume loss due to aging or parenchymal thinning. Patients with such saline implant-related problems often consider removal of their implants but fear the resulting additional loss of volume and deflation that occurs. Implant exchange is therefore often performed for recipient site soft tissue problems, not for problems related to the prosthesis, per se. Indeed, breast implant revision strategies have not historically focused on altering the soft tissue of the recipient site but have focused on selecting a prosthesis that will be better tolerated in it. The recent advances in fat transplantation to the breast for augmentation have initially sought to employ fat for primary core volume replacement . Some studies have reported a long-term 250cc average augmentation or over a doubling of breast volume using transplantation of un-manipulated donor fat documented by MRI. The purpose of the present communication is to describe the feasibility of complete removal of breast implants with simultaneous “exchange” using transplanted fat.
Methods/Technique:
Five consecutive patients with saline implants desiring implant removal were seen over a nine month period. Implant related complaints ranged from excessive upper pole fullness, capsular contracture, excessively wide cleavage gap, and residual, untreated breast ptosis. All patients underwent breast three-dimensional imaging to determine their combined natural breast + implant volume. They then underwent non-operative pre-expansion using the BRAVA device for two weeks. Increased thickness of the overlying breast soft-tissue and an overall quantitative soft-tissue volume increase of 100% was documented as a prerequisite for intervention. Patients then underwent cosmetic liposuction and resultant fat transplantation to the breast with simultaneous removal of the saline implant. The details of this technique will be outlined. At follow-up periods ranging from nine months to one year postoperative, three dimensional breast imaging was repeated to quantify resultant breast volume.
Results/Complications:
In all cases, post-explantation breast volumes 9-12 months postoperative by quantitative 3D imaging were equal to or greater than the pre-explantation composite volumes of breast and implant. No seromas developed in the implant pockets during expansion and all implants were unaffected by the pre-expansion at the time of removal. There were no complications, no palpable cysts or masses as late as 12 months postoperatively. Recipient site pre-expansion, used two weeks prior to fat grafting may have both practical and theoretical benefits in increasing the volume and recipient site microcellular environment of subcutaneous tissue overlying the prosthetic implant, allowing the subcutaneous insertion of a sufficient core volume of donor graft at the time of prosthetic explantation. Pre-expansion affords a more abundant space, completely independent from the sub-glandular or sub-muscular planes. In this new space, the “third space” of the breast, it is possible to technically transplant fat into the breast subcutaneous tissue and alleviate breast asymmetry due to pocket distortions caused by capsular contracture or by implant pocket drift. Pre-expansion may also enhance the reliability of survival of grafted adipocytes, the mechanism of which has been discussed in previous communications. There is probably no better situation to compare the principles and technical strategies of prosthetic implants to fat grafting than to observe the results of both techniques in the same patient.
Conclusion:
Breast augmentation using implants is the gold standard for core volume enhancement, and will likely remain as such for many years to come. This report highlights a viable alternative approach in selected patients presenting with implant complications with a new technique of implant exchange, namely that of augmenting the overlying soft tissue of the subcutaneous space with fat, while at the same time removing the prosthesis from the sub-muscular or sub glandular space. This simultaneous implant “exchange”, with fat - termed “SIEF”, can also be used to address capsular contracture, bottoming out, and the aesthetic compromise of these conditions. Recipient site pre-expansion and simultaneous implant exchange with fat “SIEF” may be added to the list of applications where fat grafting to the breasts may have early clinical utility.