Introduction
Severe asymmetry is one of the most common reasons to perform breast augmentation in patients under the age of 18 [
1]. Congenital breast asymmetry particularly affects young women in puberty, and patients often face corrective surgery at a young age. The long-term outcome of the surgical treatment is therefore crucial.
Implant augmentation is the standard procedure in the treatment of asymmetry, volume deficits, or micromastia [
2]. For patients with congenital breast asymmetry, implant augmentation is usually associated with the need to replace the implant several times during the course of their lives. Hence, surgical procedures are required that provide better long-term stability. Over the last few years, some promising techniques have been developed based on autologous fat transfers, with lipograft being one such approach. In previous work, we demonstrated that enriched autologous fat grafting offers good long-term results in patients presenting midface deficiency, with the procedure clearly improving facial volume loss and skin quality. [
3]
In this study, we examine the long-term outcomes for patients with congenital breast asymmetry who underwent either lipograft or silicone implant augmentation. Since both surgical methods are described differently in the literature, we present the protocols we implemented below. Regarding the long-term results, we analyze both patient satisfaction and objective parameters, such as postoperative volume difference and symmetry. We hypothesize that breast augmentation with lipograft offers at least similar objective and subjective long-term results as breast augmentation with silicone implants.
Discussion
In this study, we compared silicone implants and lipograft as techniques available to correct congenital breast asymmetry. Since surgery is usually performed early on in a patient’s life, long-term satisfaction with the results over many years is decisive. We thus evaluated the patients in our collective on average 6.8 years after their surgeries.
In order to measure the long-term patient-related outcome, we implemented the Breast-QTM questionnaire.
Lipograft and implant therapy yielded similarly good results (with an average subjective long-term outcome satisfaction of 74 % for the whole study population). We thus consider both therapies as current and relevant, confirming the findings of a study conducted by Sandsmark et al. [
25], in which no significant difference between therapy with or without implants could be detected. Additionally, our study supports the results of Kuzbari et al. [
26]. Although their study had a different focus and did not take lipograft into account, they also reported long-term satisfaction with the correction of congenital breast asymmetry, and general patient satisfaction with the long-term outcome.
A drawback of the Breast-Q
TM lies in the fact that the questionnaire lacks any question on satisfaction with breast symmetry after surgery. Hence, we added an additional question, which revealed equal results for both surgical methods. Although the data demonstrated large deviations, patients were satisfied on average with their breast symmetry in the long term. This is consistent with our objective results on symmetry, as our newly developed symmetry index revealed good results for both methods (93 %). The Department of Plastic Surgery at The University of Texas MD Anderson Cancer Center, Houston, found that a substantial proportion of women (50.6 % of a non-operated cohort) exhibit a volume difference of greater than 50 ml between the right and left breasts [
27]. The MDACC study provides normative data on the extent of breast asymmetry in preoperative patients that can guide us in setting realistic goals for reconstruction procedures. Indeed, our postoperative cases demonstrate symmetries closely resembling those of natural breasts.
However, some patients reported postoperative numbness or hypersensitivity. This was also observed in other studies, including that by Heine et al. [
28], who described less impairment of sensitivity of the breast after lipograft than after implant reconstruction. As previously described, the objective assessment of breast sensitivity is of great interest and should be evaluated in follow-up work [
28].
Anthropometric measurements utilized in the Breast-V formula provide a valid approximation of the breast volume [
9]. However, three-dimensional imaging with Vectra
® in combination with Breast-Sculptor
TM (Canfield Scientific, USA) is a validated method for calculating breast volumes as well. Indeed, we were able to reveal a good correlation of breast volume differences when comparing the Breast-V approximation and the three-dimensionally based calculation.
Of course, three-dimensional imaging is superior to anthropometric measurement, as it creates a digital twin, and thus allows for further comparisons without needing an additional, physical examination. This makes it possible to analyze even small volume deficits or scars, which are not represented by anthropomorphic measurements.
The oncogenic effects of fat grafting remain controversial [
29,
30]. A retrospective study published in 2016 [
31], which included 719 patients with benign and malignant breast disease and fat grafting, revealed no evidence of an increase in the incidence of locoregional recurrence, systemic recurrence, or new onset of breast carcinoma. Since breast augmentation with silicone implants presents long-term safety concerns (ALCL, capsular fibrosis, leakage) and forcibly leads to implant exchanges, it could prove advantageous to perform surgery on young patients with congenital breast asymmetry using lipograft. In addition, unilateral breast augmentation with silicone implants results in a difference in the feel of the breast and an asymmetry in the palpation findings.
Lipograft as means of breast augmentation required on average 2.9 sessions to achieve the desired result, which is significantly more than in the implant group (1.3 sessions). On average, both methods required a similar amount of operation time per session. As mentioned before, patients with congenital breast asymmetry are usually treated very early in their life, leading to several implant replacements. Hence, compared to lipograft, the number of operations required for implant augmentation is expected to be greater over the total lifetime of the patient. Furthermore, studies revealed that lipografts can be enriched with progenitor and stem cells using mechanical shear stress only, without causing any manipulation of the cells’ secretome [
32]. This could improve the uptake of adipose cell transplantation and improve patient satisfaction with autologous fat transfer.
A limitation of this study is clearly its small sample size. Although the sample size is common for congenital breast asymmetry studies [
26,
33,
34] and our two groups are very similar in terms of age and BMI, our collective size of 32 allows only limited generalizations. In the future, a multicenter approach may generate more focused results considering improvements in lipograft processing and lighter implants.
Conclusions
In this study, we demonstrate that there were no significant differences in the satisfaction with long-term outcome between lipograft and silicone implant augmentation, either subjectively or objectively, in our study population. Both surgical procedures afforded good levels of satisfaction with surgical outcome and breast symmetry. Lipograft needed more sessions to achieve the desired result ab initio, but implant augmentation requires several implant replacements over the course of young patients’ lifetimes.
On the one hand, the tissue compatibility of breast implants may improve in the future and thus require fewer implant replacements. On the other hand, the uptake of adipose cell transplantation may improve as well, such that fewer surgeries will be necessary. Therefore, further prospective studies and investigations will be needed in the future to compare the competitive surgical techniques of breast augmentation in congenital malformations.
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