ABS Trainee Fellowship, France - Lorna Cook

I am extremely grateful to the Association for awarding me this Fellowship, which enabled me to visit the Centre Léon Bérard in Lyon, France for two weeks.

My primary intention was to learn more about the applications of lipomodelling in breast surgery from Mr Emmanuel Delay, a world-renowned plastic surgeon, who has over 14 years of experience with this technique and one of the largest case series.

The majority of my time was spent in the operating theatres, observing not only Mr Delay but also the other plastic and breast surgeons in the department, each of whom provided me with detailed explanations of their operations. I was surprised to find that the reconstruction technique offered to the majority of women post-mastectomy, was autologous latissimus dorsi(LD) flap reconstruction in combination with lipomodelling. This meant that the majority of reconstructions performed are entirely autologous in nature, with implant reconstruction being much less commonly used technique. Furthermore, unlike in the UK, use of acellular dermal matrices as an adjunct to implant-based breast reconstruction is used very infrequently.

The use of lipomodelling to augment the volume of the LD muscle obviates the need for an implant in women undergoing unilateral reconstruction, for whom the volume of the LD muscle alone is insufficient. I was fortunate to watch Dr Delay and his colleagues demonstrate the technique in several patients. Dr Delay describes the procedure as “like a millefeuille” (the French patisserie, composed of multiple layers of alternating pastry and cream), in that fat harvested from a patient’s buttocks, thighs or abdominal area is injected directly into the LD flap muscle in consecutive layers, from deep to superficial. It was explained that relatively large volumes (around 400cc) can be injected per session and by taking care not to inject fat into the subcutaneous tissue rather than the muscle, there are few incidences of fat necrosis. I was impressed by the aesthetic appearance of the reconstructed breasts in the immediate post-operative period, particularly the degree to which the flap volume was increased just by fat transfer alone. Patients are, however, told from the outset that their reconstructive surgery is an ongoing process requiring several repeat sessions of lipomodelling over the course of a year, before the final result can be achieved.

The women whom I observed attending for their subsequent sessions of lipomodelling often underwent additional adjustment procedures at the same time. Commonly fat transfer was also used to improve the cosmesis of the LD donor site scar which often becomes tethered to underlying tissue. I also observed the combined use of both liposuction and lipofilling to adjust the breast contour – to improve for example, poor prominence of the cleavage region and to remove excess lateral tissue or “dog ears”. I was also very fortunate to observe the less commonly used applications of lipomodelling – to create a breast in a 14 year old girl with Poland’s Syndrome and to improve appearance in patients with congenital breast asymmetry or tuberous breasts. In all these cases, lipomodelling was used alone without any additional procedures with very impressive results and minimal scarring.

In addition to spending time in the operating theatres at the Centre Léon Bérard, I also accompanied Dr Delay to his outpatient clinic and to his private operating lists at the nearby Clinique Charcot. Interestingly, the most commonly performed procedure was breast reduction surgery, with cosmetic augmentation being much less popular.

A particular highlight of my visit was attending the trainee teaching session. This followed an “MDT” style format where an interesting or controversial case was presented by a senior surgeon accompanied by a discussion of the patient’s pre-operative photographs. Trainees were then invited to give their opinion on case management, made all the more impressive by the fact they did so in perfect English for my benefit! Each case discussion was completed by examining the actual post-operative photographs and a discussion of the particular difficulties or complications that had occurred.

Overall, I thoroughly enjoyed my visit, learnt a huge amount and was made to feel extremely welcome. I would certainly recommend this fellowship to other trainees. In addition to the inspiring clinical experience, I really enjoyed discovering Lyon which I found to be a beautiful, rather quirky city with an interesting old quarter and wonderful food.

I would like to thank Dr Delay, Dr Toussoun, Dr HoQuoc, Dr Carrabin and Dr Faure together with their teams, as well as the Association of Breast Surgery for giving me the privilege of this fantastic experience.

Lorna Cook