Fat Injection From Filling to Regeneration

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BREAST
Aesthetic
S e c t i o n F o u r

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Augment at ion o t he Br east
and uber ous Br east
Sydney R. Coleman
C h a p t e r 3 6
I c

654
Part III • Clinical Applications • Breast: Aesthetic
Between November 99 and June , I per ormed at gra ing to the breasts o patients. Indica-
tions included micromastia, postaugmentation de ormity, tuberous breast de ormity, Poland syndrome,
and postmastectomy reconstruction de ormities. With my earliest patients I had great successes and be-
gan discussing them discreetly with colleagues as early as 99 . A er lectures that I gave on at gra ing
to the breast at Georgetown and Marseilles, Scott Spear and Emmanuel Delay began gra ing at to the
breast. I ollowed my earliest patients over the next to years, compiled my observations retrospec-
tively, and published them.12 T ere was signif cant improvement in breast size and/or shape in all women
treated, and all had breasts that were so and natural in appearance and eel. Postoperative mammo-
grams identif ed the changes one would expect a er any breast procedure.
Based on years o experience with at gra ing to the breast (and with an o cial moratorium still in
orce), I began speaking about this procedure at international meetings and was subsequently invited to
present my experience in May at the ASPS meeting and published my series in March .12 A er
I presented my experiences at major national plastic surgery meetings in North America as well as in Eu-
rope and Asia, the ASPS was persuaded to establish a task orce to scientif cally reevaluate at gra ing to
the breast. At the initial meeting in October , the task orce “reviewed the scientif c literature, crit-
ically appraised the in ormation available, and developed evidence-based practice recommendations.”
T e task orce report was approved by the ASPS/Plastic Surgery Education Foundation (PSEF) and the
American Society o Aesthetic Plastic Surgery (ASAPS) in October , which led to reversal o the
earlier moratorium. T is new statement conf rmed that at gra ing was considered sa e enough to be-
come part o our clinical practices. T e ollowing excerpts are rom this report, published in Plastic and
Reconstructive Surgery in 913:
Fat gra ing may be considered or breast augmentation and correction o de ects associated
with medical conditions and previous breast surgeries; however, results are dependent on tech-
nique and surgeon expertise. . . .Fat gra ing to the breast could potentially inter ere with breast
cancer detection; however, no evidence was ound that strongly suggests this inter erence. . . .
Radiological studies suggest that imaging technologies (ultrasound, mammography, and MRI)
can identi y the gra ed at tissue, microcalcif cations and suspicious lesions; biopsies may be
per ormed i needed or additional clarif cation.
T e position statement issued by the plastic surgery societies, along with the positive results o the in-
creasing world experience with at gra ing to the breast, has served as a springboard or plastic surgeons
to initiate more def nitive studies o the procedure’s e cacy and sa ety.
Now a large percentage o plastic surgeons worldwide are gra ing at or augmentation and breast recon-
struction, and it has become part o the standard o care. Many scientif c reports have emerged on the
e cacy o at gra ing or breast reconstruction,14-22 or the treatment o radiation damage to the chest,18
reduction o breast capsular contracture,18 and so tissue coverage o breast implants.18,20,23-27
I n d i ca ti on s
In this chapter I will address the aesthetic augmentation o a breast or shaping with the Coleman tech-
nique (see Chapter ). T e case I present is that o a patient with a mildly tuberous breast, which rep-
resents a special challenge by having a constricted lower pole, but the principles are basically the same as
in at gra ing or simple breast augmentation.

655
Chapter 36 • Augmentation o the Breast and uberous Breast
T e degree o sculpting possible with Coleman at gra ing is clear when applied to women who have
tuberous breast de ormities. In this situation, little or no no at is placed under the nipple-areola com-
plex, while the skin envelope o the breast is selectively expanded with at placed immediately beneath
the skin. Fat gra ing is thus able to change the relative proportion o the breast to the areola, creating a
more natural-appearing and shapely breast.
In patients with breast asymmetry, at gra ing allows either dramatic or subtle shaping to produce a
more aesthetic, symmetrical contour. T ese small changes are very di cult to achieve without the use
o transplanted at. Fat gra ing to the breast is a valuable adjunct to breast reconstruction (see Chapter
40), and with or without alloplastic breast implants, gra ing may provide a substitute or much more
extensive procedures, such as ree aps.
Patients with de ormities resulting rom their breast implants o en have inadequate so tissue coverage
over the implants and/or obvious capsular contractures. Gra ed at can provide additional subcutaneous
thickness to disguise visible edges and wrinkling o implants and decrease the palpability o the under-
lying implant. T is is especially true in thinner patients. In addition, the placement o at around breast
implants can result in a so ening o the breast capsules, which has also been reported by Delay et al16
and Rigotti et al.18
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Preparation
Harvesting sites are selected only to enhance body contour and avoid iatrogenic donor site de ormities,
since no overriding clear correlation between donor site location and longevity o the implanted tissue
has been demonstrated.28,29 I pre er to harvest at rom the torso, especially the back, love handles, and
abdomen, because a reduction in these areas enhances a woman’s body proportion and accentuates the
larger breasts with a narrower waist.
Anesthesia
I usually use a general anesthetic or propo ol because o the large volumes that must be harvested or
at gra ing to the breast. I inf ltrate a solution o 0. % lidocaine with :400,000 epinephrine in Ringer’s
lactate solution into the donor and recipient sites.
Incisions for Harvesting
Incisions are made with a No. blade scalpel, and a blunt nine-holed Coleman harvesting cannula is
used to di usely inject Ringer’s lactate solution with :400,000 epinephrine in a ratio o ml o solution
or each cc o at harvested. For the posterior torso, I usually make one incision in each sacral dimple
and one incision in the midline o the back. T ese may be supplemented by incisions laterally to acilitate
harvesting in the hip or ank.
From the anterior approach, I most o en place incisions in the pubic hair and umbilicus, with occa-
sional incisions in the anks or hips to acilitate removal rom the more lateral regions.

656
Part III • Clinical Applications • Breast: Aesthetic
Cannulas or Harvesting
Multi-hole aspirator
Fig. 36-1
Fat is harvested in most o the cases with a 10 cc syringe attached to a nine-holed, blunt-tipped Coleman
harvesting cannula. T e larger-gauge cannula is used here. A combination o slight negative pressure and
a curetting action allows parcels o at to move through the cannula, through the Luer-Lok aperture, and
into the barrel o the syringe, resulting in minimal mechanical damage to the atty tissue.
Harvest
A er harvesting, the at is centri uged in the 10 cc syringes or 3 minutes at 1300 g. T e oil layer is de-
canted and the aqueous component drained. Codman pads are used to wick o the remaining oil, and
the ref ned, unwashed at is then trans erred to 3 cc Luer-Lok syringes.
Incisions or Inf ltration
Fig. 36-2
T e incisions are positioned to allow placement rom two directions into each area to be gra ed. Usually
three in ramammary incisions, an areolar incision, and an axillary incision on each breast are enough
to provide access to the entire breast. Incisions on the sternum, décolleté, or sur ace o the breast should
be avoided.

657
Chapter 36 • Augmentation o the Breast and uberous Breast
Cannulas or Placement
Type I
Fig. 36-3
Blunt -gauge inf ltration cannulas, 9 or cm in length, are used to place the at through mm in-
cisions. Blunt cannulas not only allow more dispersion o the gra ed tissue in small aliquots, but also
reduce the possibility o an intravascular injection.30 A type I Coleman cannula is most o en used, but i
there is scarring or other tissue resistence, a type II or even type III Coleman cannula may acilitate the
surgeon’s ability to push the cannula through the denser tissues such as scars and breast parenchyma.
For sa ety reasons to avoid intravascular emboli, at no time are sharp needles used or injection into the
breast. T e at is inf ltrated only while the cannula is being withdrawn, not during the advancement o the
cannula. Approximately . cc is placed with each withdrawal o the cannula. T is approach maximizes
the sur ace area o contact between the surrounding tissues and the gra ed at. T e goal is to allow each
parcel o atty tissue access to a blood supply, thus maximizing the potential or survival and minimizing
the possibility o at necrosis. Also, or sa ety reasons, cannulas o more than cm in length should be
used with extreme caution, because pneumothoraxes have been reported by even the most experienced
surgeons while inf ltrating at in the thorax.
Method o Inf ltration
T e Coleman technique used or placement must be one that acilitates survival o the atty tissue, not
only by minimizing trauma during harvesting and ref nement, but also by placing the living tissue in a
manner that optimizes the potential or vascularization. When at is placed into the recipient site in large
clumps, some o the at cells may be too ar rom a blood supply. T is can lead to at necrosis, causing not
only lumps and calcif cations, but also the ormation o liponecrotic cysts. Bircoll7 advocated the place-
ment o atty tissue in amounts as small as mm per pass. At the time, the idea o making passes in
the breast to place cc o at was considered “ludicrous.”31,32 T e technique described in this chapter
is based on an even smaller aliquot, with each pass o the cannula depositing rom ⁄5 to ⁄2 cc per pass,
depending on the length o the deposited path. Dramatic volume corrections are possible, but the time
requirement or such a procedure should not be underestimated. T e time to harvest, ref ne, and place
at into the breasts in this ashion takes many hours. In general, placement o atty tissue into the breasts
using this method takes approximately hours or the f rst cc and approximately 4 minutes or each
additional cc placed.

658
Part III • Clinical Applications • Breast: Aesthetic
Level o Inf ltration
Fig. 36-4
T e breasts are shaped by layering the at into di erent levels until the desired contour is achieved.
Although a breast implant augments by expanding the retromammary or retropectoral space, the struc-
tural at gra ing technique allows selective augmentation and contouring rom the chest wall to the skin.
In most o my earlier cases, the largest portion o the at was inf ltrated into the pectoralis major muscle,
ollowed by inf ltration into the retropectoral and prepectoral spaces. T ose volumes were located close
to the chest wall and provided a di use increase in the chest size without specif c shaping. Shaping o the
breast is accomplished by placing aliquots subcutaneously into the superf cial breast planes. Placement
into the parenchyma o the breast should be limited but is necessary at times to increase projection.

659
Chapter 36 • Augmentation o the Breast and uberous Breast
Volume Ranges
With structural at gra ing, corrections with as little as 0 cc to more than 400 cc o at gra ed di usely
in the breast and surrounding tissues produce long-lasting results. T e amount placed always depends
on the e ect desired. As with any surgical procedure, the technique used, the execution o the technique,
the experience o the surgeon, and even variations between patients a ect the outcome.
TECHNIQUE
A basic strategy o the at gra ing technique is the placement o at in small aliquots rather than large
clumps. Minimizing the amount o atty tissue gra ed with each pass o the cannula maximizes the sur-
ace area o contact between the gra ed at and the recipient tissue. Decreasing the size o each injected
volume o atty tissue decreases the distance o the innermost at cells to the surrounding capillaries. T e
proximity o the newly gra ed at to a blood supply encourages survival and minimizes the potential or
at necrosis and later calcif cation.
Fig. 36-5
T is 27-year-old woman presented or primary breast augmentation with autologous at. She had under-
gone reconstruction or tuberous breasts elsewhere years earlier, but she was not happy with her small
breast size. She wore an external vacuum expansion device or 8 hours a day or 4 weeks be ore surgery
to maximize the tissue envelope or at placement. Her preoperative mammograms showed scattered
benign calcif cations, probably related to her previous surgery. Because the tuberous condition had been
previously treated, the preoperative markings were no di erent rom those or a typical “normal” patient.

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Part III • Clinical Applications • Breast: Aesthetic
Planning
Fig. 36-6
T e goal was to create a uller, natural teardrop shape by placing at into each quadrant o the breast
( ocusing on the more def cient medial and in erior areas) as well as into the cleavage, and the retroare-
olar space ( or projection). We marked donor sites (purple marker) in the love handles, posterior hips,
sacrum, posterior medial thighs, lateral thighs (all approached rom the prone position) as well as the
upper and lower abdomen and anterior and medial thighs. T e breasts were divided into our quadrants,
and the areas or placement were delineated with green marker. T e in ramammary olds were marked
in orange.
Anesthesia
A general anesthetic was used or this patient, with a laryngeal mask airway (LMA). T e donor sites were
inf ltrated with 1:4 , epinephrine in Ringer’s lactate solution and .2% lidocaine (about 5 ml total
was used in the donor sites).

661
Chapter 36 • Augmentation of the Breast and uberous Breast
Donor Sites
Fig. 36-7
T e donor sites were chosen to enhance the patient’s feminine shape by removing most of the harvested
fat from the area of the waist down to the hips and up to the breasts.
Fig. 36-8
Purple marks the areas to be removed, red marks possible incision sites, and orange indicates areas in
which care was necessary to avoid excessive removal, such as the transition zone between the back and
the love handles.

662
Part III • Clinical Applications • Breast: Aesthetic
Harvest
Fig. 36-9, A-D
A
B
C
D
When a midline back incision and a curved 3 cm cannula are used, the entire love handles and f anks
can be approached without lateral incisions.
Fig. 36-9, E and F
E
F
T e incisions in the sacral dimple can be used to harvest not only rom the sacrum and lumbar regions,
but also rom the hip and f ank.

663
Chapter 36 • Augmentation o the Breast and uberous Breast
Surgery began with the patient in the prone position, a er success ul induction o anesthesia and place-
ment o an LMA. T e patient was maintained under deep intravenous sedation and breathed on her
own. A er inf ltration with tumescent solution (Ringer’s lactate solution with epinephrine 1:400,000 and
lidocaine 0.2%), using blunt Coleman multiholed cannulas, the ollowing volumes were removed with
manual suction: right love handle, 170 cc; le love handle, 210 cc; right hip, 100 cc; le hip, 70 cc; right
sacral dimple, 70 cc; le sacral dimple, 70 cc; right medial thigh, 50 cc; le medial thigh, 50 cc; right
lateral thigh, 100 cc; and le lateral thigh, 120 cc, or a grand total o 1010 cc. T e at was processed in
the standard ashion, separating out 2.5 cc aliquots based on density. T e at was noted to be f brous.
(T is is a common f nding in healthy, f t patients.) T e incisions were closed with 5-0 Ethilon interrupted
sutures.
Fig. 36-10
T e patient was care ully turned to the supine position and reprepped and draped or urther suction.
A total o 50 cc was removed rom the upper abdomen, 50 cc rom the lower abdomen, and 40 cc rom
each medial thigh, yielding a total o 180 cc harvested in the supine position. (We did not suction the
preoperatively marked anterior thighs, since su cient volume was obtained without using this area.)
T e donor incisions were closed with interrupted 4-0 Ethilon sutures. T e grand total volume harvested
( rom both prone and supine positions) was 1190 cc, and processing yielded 15 cc o usable at.

664
Part III • Clinical Applications • Breast: Aesthetic
Volumes to Be Placed
VOLUMES PLACED
(total 607.5 cc)
Right
breast (cc)
Left
breast (cc)
Upper quadrant
Medial quadrant
Lower quadrant
Lateral quadrant
Cleavage
Periareolar
Retroareolar
TOTAL
10, Ø20 = 30
62.5
75
50
Ø15
22.5
45
300
10, Ø20 = 30
75
70
50
Ø15
22.5
45
307.5
The symbol indicates the densest level (bottom of each centrifuged
10 cc syringe); indicates the next level, and Ø the least dense fat.
Fig. 36-11
T e chest was then prepped and draped in the usual sterile manner. Stab incisions or placement o at
were made in the medial, lateral and central in ramammary olds (as indicated by red dots in the preop-
erative markings), as well as in the upper medial areolas. T e breasts were inf ltrated with a small volume
o the tumescent solution to reduce bleeding. Using blunt Coleman placement cannulas, a total o 300 cc
was placed into the right breast/cleavage, and a total o 307.5 cc was placed on the le side.

665
Chapter 36 • Augmentation o the Breast and uberous Breast
Placement
T e decision about what level o at density to use in an area is based on whether one is looking to im-
prove texture, or just create volume. Almost any level o density can be used in the breast, unless scars
are being treated—high-density at is pre erred or treating scars. In this case, the higher-density at was
used in the lower quadrants and retroareolar areas, where the most signif cant structural changes were
planned.
Fig. 36-12, A and B
A
B
On almost every patient I begin with placement into the lower pole, but in this particular patient it was
especially important, because this was the most important shaping that would take place in her breast.
T e placement began against the dermis rom the medial incision with a 9 cm Coleman type I cannula,
switching to a 1 cm cannula on occasion.
Fig. 36-12, C and D
C
D
A er placing 20 cc rom the medial incision, I switched to the lateral incision or placement into the
same area o the lower pole o the breast.

666
Part III • Clinical Applications • Breast: Aesthetic
Fig. 36-12, E and F
E
F
A er another 20 cc o at was inf ltrated rom the lateral incision, I approached the same area rom the
areolar incision. From all three incisions, at was placed over the entire lower quadrant, with special at-
tention in this patient to placement that would lower the in ramammary old to the new location several
centimeters below the current location.
Fig. 36-12, G and H
G
H
A er 0 cc o at was placed into each lower quadrant, the medial quadrants were inf ltrated rom the
areolar, medial, and middle in ramammary incisions. Again, all placement was subcutaneous. T e me-
dial quadrants were elt to be remarkably def cient, so larger amounts were inf ltrated here (right, 55 cc;
le , 50 cc) than was planned or the lateral quadrants.
Fig. 36-12, I and J
J
I
Next the lateral quadrant was inf ltrated through the lateral in ramammary incisions with a signif cantly
smaller quantity o at.

667
Chapter 36 • Augmentation o the Breast and uberous Breast
Fig. 36-12, K and L
K
L
T is placement extended up into the axilla to f ll in the de ect created by the inter ace o her large pecto-
ralis muscles with her small breast.
Fig. 36-12, M and N
M
N
T e lateral quadrant was also approached through the middle in ramammary old incision. T e place-
ment remains superf cial, especially in this patient, to attempt to correct the tuberous de ormity. Note
the dimpling o the skin as the cannula passes superf cial to the skin.
Fig. 36-12, O and P
P
O
Even with the small amount placed into the lateral quadrant, the at is inf ltrated rom three di erent in-
cisions and presumably three di erent directions. Every attempt should be made to place the at aliquots
in small quantities with each pass and rom at least two and even three directions when possible.

668
Part III • Clinical Applications • Breast: Aesthetic
Fig. 36-12, Q
Q
Switching to a 15 cm cannula extends the reach so that distant areas can be inf ltrated with atty tissue
in several directions.
Fig. 36-12, R and S
R
S
Finally, the lateral sternum cleavage area was approached. A 15 cm inf ltration Coleman type I cannula
is always used in these cases to reach the distant site. In this patient, 40 cc was placed on each side. T is
amount is about the usual or most patients.

669
Chapter 36 • Augmentation o the Breast and uberous Breast
Fig. 36-12, T and U
T
U
T e area was approached rom the areolar incision with a 15 cm type I cannula to provide another di-
rection o placement.
Fig. 36-12, V and W
V
W
A er placement was complete into all o the sites, some tissue was placed into the retromammary region.
Axillary incisions acilitated f nding the plane behind the breast. In this patient, 85 cc was placed on the
right and 0 cc on the le in the lower hal o the breast; into the upper hal o the breast in the retro-
mammary region, 70 cc was placed on the right and 4 .5 cc on the le .

670
Part III • Clinical Applications • Breast: Aesthetic
Fig. 36-12, X and Y
X
Y
All o the incisions were used or this deep placement in the retromammary space with 15 cm 14-gauge
type I cannulas. T e larger cannulas are used or sa ety, because the sti er, bigger cannulas allow greater
control in placement. Recently I have begun using the old Coleman harvesting cannulas (bucket-handle
type) or placement in this plane and around breast implants.
A er at placement into all o the planned areas, the patient was brought to a sitting position. We deter-
mined that her breast projection was def cient, and it did not appear that the lower poles had as much
curvature or pseudoptosis as had been hoped.
Fig. 36-12, Z and AA
Z
AA
T rough the axillary incision and the other our, another 35 cc was placed into the constricted right
lower pole and another 3 cc into the le lower pole. T is was an extremely di cult placement, because
there was not much space, and several times it was debated whether we should release the apparent ad-
hesions in these areas to allow more curvature o the lower pole. I elt that this would destabilize the at
I had already placed and would probably not allow me to place more at in a vascularized, healthy ash-
ion. T ere ore no release o any sort o adhesion or constriction was per ormed. However, to enhance
projection, 3 cc was placed on the right and 1 cc on the le deep in the parenchyma. No tissue was
intentionally placed behind the areola at any time.

671
Chapter 36 • Augmentation o the Breast and uberous Breast
Fig. 36-12, BB and CC
BB
CC
Several times during the procedure, the patient is placed in a sitting position to evaluate the ef ect o the
at transplantation. In these views, taken toward the end o the procedure, one can see the beginning o
a release o the constricted lower pole. More placement simply was not possible into the stif lower pole.
Fig. 36-12, DD and EE
DD
EE
T e breast incisions were closed with 5-0 Ethilon sutures. Reston oam was placed over the in ra-
mammary olds and between the breasts to prevent migration o at. Compressed Reston oam was also
placed over the areolas to prevent herniation, since the patient had a history o tuberous breasts. T e
Reston oam was secured with compression in all places with egaderm. T e surgical bra cushioned with
Kerlix was placed, as was a lower body compression garment.

672
Part III • Clinical Applications • Breast: Aesthetic
T e patient was seen or routine ollow-up on the third postoperative day. We were able to attach the ex-
ternal vacuum expansion domes at that time. We instructed the patient to begin using the device nightly
and to try to work up to 8 hours per day again. We saw her routinely during her initial postoperative
course, and she was able to use the expansion device or 8 hours a day or about 4 weeks. Her postoper-
ative course was unremarkable, and the patient was happy with her results.
T ree-Year Follow-up
T e patient returned a little over 3 years a er her surgery and was thrilled with her results. Her breasts
had a lovely shape, the breast incisions were not visible, and the natural ullness and size were in excel-
lent proportion to the rest o her body. She was happy with the added benef t o sculpting o the anks
and thighs.
R esul ts
BREAS
Case 1
Fig. 36-13, A and B
A
Breasts “bottoming out” while retaining nipple position
B
T is 31-year-old woman presented specif cally or breast augmentation. She said she was “tired o wear-
ing padded bras” and wanted her breasts to be more proportional to the rest o her body. She specif cally
asked or more cleavage; she wanted her breasts to “bottom out” naturally and not be too “perky.” She
pointed out that she had strong pectoralis muscles already, so she did not want much augmentation into
the outer upper poles o the breast. She had not considered silicone implants and liked the natural idea
o using one’s own at.

673
Chapter 36 • Augmentation o the Breast and uberous Breast
Fig. 36-13, C and D
C
D
She had no amily history o breast disease, had never noted any nodularities or irregularities in her
breasts, and had not had a mammogram. During her second consultation, we reviewed her photographs
and designed her surgery using tracings o her body.
She returned or a third appointment 2 months be ore her planned procedure with a mammogram that
was normal. At this time we resumed the discussion o how big her breasts would be. I told her that the
f nal size is not as predictable as I would like, and that I would harvest as much at rom her body as I
elt I could while minimizing the possibility o donor site de ects. At that time, I had most o en seen a
change o one cup size or every 00 cc o ref ned at gra ed. We agreed that I would place only about
00 cc o ref ned at into each breast.
Anesthesia or this procedure was produced through an epidural with intercostal blocks (20 ml o 1%
lidocaine with 1:100,000 epinephrine) and sedation. T e donor sites were inf ltrated with 1:400,000 epi-
nephrine in Ringer’s lactate solution (800 ml total was used in the body).

674
Part III • Clinical Applications • Breast: Aesthetic
I

J
E

F

G

H
Fig. 36-13, E-J
T e patient did not have a su cient amount o at in any one area o her body; there ore we chose to
harvest lesser amounts rom many areas. In a prone position the ollowing amounts were harvested
using 15 and 23 cm straight and curved Coleman cannulas: love handle, right, 1 0 cc, lef , 1 0 cc; each
inner thigh, 0 cc; each inner knee, 20 cc; lateral thigh, right, 180 cc, lef , 1 0 cc; lateral buttock, right,

675
Chapter 36 • Augmentation o the Breast and uberous Breast
40 cc, le , 0 cc. From the supine position, the ollowing amounts were harvested: abdomen, 80 cc; lat-
eral ank, right, 0 cc, le , 0 cc; inner thighs, right, 0 cc, le , 20 cc; and rom the anterior thighs, right,
0 cc, le , 40 cc. A total o 1110 cc o subcutaneous tissue was harvested. T e at was ref ned as described
previously to yield 0 cc o ref ned at, not all o which was used in the procedure.
K
VOLUMES PLACED
(total 629 cc)
Right
(cc)
Left
(cc)
Pectoralis muscles
Breast tissue (subcutaneous)
Periareolar region
Sternum
120
120
52
40
120
100
37
40
Fig. 36-13, K
First, 120 cc was inf ltrated into the pectoralis muscles on each side. Into the subcutaneous planes, avoid-
ing the parenchyma o the breasts, 120 cc was placed into the right breast and 100 cc into the le breast.
Into the periareolar region another 2 cc was placed on the right and cc on the le . Finally, 40 cc was
inf ltrated into the sternal region on each side to promote cleavage. A small hematoma ormed in the le
breast during the insertion, but no treatment was necessary. T e total actual operating time was hours
and minutes, with an anesthesia time o 8 hours and minutes.

676
Part III • Clinical Applications • Breast: Aesthetic
Preoperative
L
1 year postoperatively
M
9 years postoperatively
N
16 years postoperatively
O
Fig. 36-13, L-O
T e patient returned or suture removal 1 week postoperatively and then was seen again at 3 and
9 months. She was extremely satisf ed with the appearance o her body and breasts, claiming that she
had changed the size o her breasts rom an A cup to a large B cup.

677
Chapter 36 • Augmentation o the Breast and Tuberous Breast
Fig. 36-13, P-U
P
Preoperative
Q
9 years postoperatively
R
16 years postoperatively
T
9 years postoperatively
U
16 years postoperatively
S
Preoperative
When the patient returned 9 years later, she was wearing a C-cup bra. She elt that, despite a 10-pound
weight loss during that time, she had a signif cant increase in volume between 1 year and 9 years. She
remains pleased with her cosmetic result 1 years a er her at gra ing procedure.

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Part III • Clinical Applications • Breast: Aesthetic
Case 2
A

B

C
D
Preoperative
E
1 year postoperatively
F
1 year after second procedure
Fig. 36-14, A-F
T is 0-year-old woman presented with a desire or larger, shapelier breasts. With the use o blunt,
multiholed Coleman harvesting cannulas, a total volume o 1040 cc was removed rom the patient’s
back, love handle areas, and hips. T e at was processed in the usual ashion to yield 53 .5 cc. T e patient
was care ully rotated, and an additional 10 cc was then harvested rom the abdomen and f ank and
processed to yield 34 .5 cc.

679
Chapter 36 • Augmentation o the Breast and uberous Breast
Fig. 36-14, G-I
G
Preoperative
H
1 year postoperatively
I
1 year after second procedure
With the use o blunt Coleman placement cannulas, a total o 422 cc was placed into the right breast and
cleavage, and a total o 44 .5 cc was placed into the lef breast and cleavage. T e punctures were closed
with 4-0 Ethilon interrupted sutures, and Band-aids were placed over the donor and graf site incisions
and punctures. A surgical bra cushioned with Kerlix and an abdominal binder were placed.
One year later, the patient returned with a desire or additional enhancement o her breasts. During
the procedure, the patient was placed into the sitting position to better assess contours. Note that we
attempted to correct the “divot” o the lef superior areola (longitudinal de ect) but were only partially
success ul. T e total volume o at placed into the right breast was 245 cc; the total volume placed into
the lef breast was 20 cc. T e patient tolerated the procedure extremely well.

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Part III • Clinical Applications • Breast: Aesthetic
TUBEROUS BREAST DEFORMITY
Case 1
Normal placement of tuberous breast
A

B
Fig. 36-15, A and B
C

D
E
Preoperative

8 months postoperatively

4 years 11 months after second fat
grafting procedure
Fig. 36-15, C-E
T is 2 -year-old woman had bilateral tuberous breast de ormity (lef column). In the f rst procedure
37 cc o ref ned at was placed in the le breast and 3 cc in the right.

681
Chapter 36 • Augmentation o the Breast and Tuberous Breast
F

G

H
I

J

K
Preoperative

8 months postoperatively

4 years 11 months after second fat
grafting procedure
Fig. 36-15, F-K
During this procedure the at was gra ed primarily subcutaneously and in a retromammary direction,
avoiding any placement deep to her areola or into the parenchyma. Eight months a er the f rst proce-
dure, her breasts look like a normal A cup (middle column).
She wanted a more signif cant augmentation, so 00 cc more was placed into the le breast and an ad-
ditional 40 cc into the right breast, as depicted in the lateral view, demonstrating normal placement.
Four years and months a er her second and last procedure (right column), she now has breasts with a
completely natural and undetectable correction as a result o at gra ing.

682
Part III • Clinical Applications • Breast: Aesthetic
Case 2
Fig. 36-16, A-I
6 months later: second procedure
D

E

F
H
G
Preoperative
I
2 years later: third procedure
A
B

C
T is 9-year-old woman presented or the treatment o a tuberous right breast. During her f rst proce-
dure, with the use o blunt Coleman single-holed and multiholed Coleman and Khouri harvesting can-
nulas, a total o 0 cc o at was removed and then processed to yield 375 cc. Attention was then turned
to the chest, where 7 .5 cc was placed into the right breast and cleavage and 30 cc was placed into the
le cleavage. T e patient was placed in the sitting position during at gra ing to observe contours, and
the right breast expanded well with placement.

683
Chapter 36 • Augmentation o the Breast and uberous Breast
Fig. 36-16, J-R
M

N

O
P
Preoperative
Q
6 months later: second procedure
R
2 years later: third procedure
J

K

L
About months later, the patient returned or a second procedure to address her remaining tuberosity
and asymmetry. At this time, 0 cc was harvested and then processed to yield 5 cc. T e total volume
o structural at placed into the right breast and cleavage was 197.5 cc; the total volume placed into the
lef breast and cleavage was 5 cc. With the use o a 1 -gauge 11⁄2-inch needle attached to a 10 cc syringe,
we per ormed vigorous release o adhesions at the superior border o the lef areola to allow the area to
descend somewhat to create symmetry with the contralateral side.

684
Part III • Clinical Applications • Breast: Aesthetic
Approximately 2 years a er the f rst operation, the patient returned to have this area addressed one more
time. At this time, 250 cc o at was harvested rom the patient’s right hip and love handles, and this was
processed in the usual ashion to yield 150 cc. A total o 107.5 cc was placed into the right breast.
T e patient was placed in the sitting position during at gra ing to observe contours. Every e ort was
made to eliminate the horizontal restriction o the lower pole without using sharp dissection, but this
was only partially success ul. When the patient was observed in the sitting position, it was determined
that the breast shape would be enhanced with at placement in the upper pole and lateral quadrant,
which had not been marked.
Case 3
Fig. 36-17, A-C
A
Preoperative
B
1 year after first procedure
C
1 year after second procedure
T is patient presented at age 21 or treatment o her bilateral tuberous breasts. A total o 710 cc o at
was harvested rom her lateral and medial thighs and processed to yield 7.5 cc. Her chest was prepped
and draped in the usual ashion. A total o 2 5 cc was placed into the right breast, and a total o 202.5 cc
was placed into the le breast. T e incisions were closed with 5-0 Ethilon interrupted sutures, the donor
sites were dressed with Reston oam and Micro oam tape, and a compression garment was applied. T e
breasts were covered with cotton “ u ,” and a surgical bra was placed.

685
Chapter 36 • Augmentation o the Breast and uberous Breast
Fig. 36-17, D-I
D

E

F
G
Preoperative
H
1 year after first procedure
I
1 year after second procedure
One year later, the patient returned or the second stage o structural at gra ing to the breasts. For this
procedure, 990 cc o at was harvested and then processed in the usual ashion to yield 0 cc. With the
use o muscle inf ltrator-type cannulas, a total o 21 cc was placed into the right breast at a superf cial
level, and another 1 0 cc was placed more deeply. For the le breast, 220 cc was placed superf cially, and
11 cc was placed more deeply. T e patient is shown preoperatively, 1 year a er the f rst procedure, and
1 year a er the second procedure was completed.

686
Part III • Clinical Applications • Breast: Aesthetic
Case 4
Fig. 36-18
Preoperative
14 months postoperatively

19 months postoperatively

51⁄2 years postoperatively
T is 1-year-old woman presented with bilateral tuberous breast de ormities that were more severe on
the le side than on the right. During her f rst procedure, a total o 7.5 cc was placed in the right
breast, and a total o 3 3 cc was placed in the le breast.
She returned 14 months later or second-stage reconstruction o this de ormity and or the treatment o
possible residual oil cysts and retracted scarring o the le breast. T e patient was brought to the operat-
ing room wearing the external vacuum expansion device and was placed in the supine position. At this
time, 1 40 cc o at was harvested rom the patient’s anks and abdomen and processed to yield 73 .5 cc.
T e external expansion device was removed, and the patient’s chest was prepped and draped.
With a type III Coleman placement cannula attached to a 3 cc syringe, approximately 1 cc o uid (which
appeared to be at and/or oil) was suctioned rom each o the two cystic areas o the le breast. T en 335
cc o processed at was placed into the right breast and 317.5 cc into the le breast. T e contours o the
breast were examined with the patient seated. Some retracted areas o the le breast were appreciated;
the adhesions in these areas were vigorously released with a 1½-inch 1 -gauge needle attached to a 10
cc syringe. T e patient is shown preoperatively and then 14 months, 19 months, and 51⁄2 years a er the
f rst procedure.

687
Chapter 36 • Augmentation o the Breast and uberous Breast
C om p l i ca ti on s
NORMAL POSTOPERATIVE COURSE: EDEMA AND BRUISING
WITH STABILIZATION AT 4 TO 6 MONTHS
Immediately a er the procedure, signif cant edema o the donor and recipient sites is present. By to
months, the volume o the breast appears to stabilize, with little apparent reduction in size over the
ollowing years. Obviously, with weight gain or dramatic hormonal changes, as seen with pregnancy or
menopause, the size o the breast and the apparent e ect o the augmentation may change.
UNLIKELY COMPLICATIONS
All patients in this series signed a separate consent orm acknowledging their awareness o the poten-
tial complications associated with inf ltrating at into the breast, including the possibility o di culty
with breast cancer detection, the ormation o calcif cations, and the ormation o cysts. In addition, the
patients agreed to have mammograms at and months postoperatively and annually therea er. T e
patients agreed that i they detected any lump or irregularity in their breasts, they were to report the
f nding immediately and comply with the recommended workup. It was emphasized to each patient that
any palpable lump should never be assumed to be a result o the gra ed at until a complete workup had
been per ormed.
In 99 , Montañana Vizcaino et al33 reported on a patient with areas o at necrosis and multiple cysts,
but no calcif cations. T is occurred only months a er at was radially injected into the breast using
one puncture site. In 99 , Maillard34 reported a similar f nding o a patient with liponecrotic cysts
year a er liposuction aspirate was injected into the breasts. Castelló et al35 reported a patient with a
large pseudocyst with a calcif ed capsule a er an unknown volume o at was injected into the breast.
In my reported series,12 patient developed a superf cial Staphylococcus aureus in ection near her sili-
cone implant. T e in ection resolved a er drainage and oral antibiotics, and her aesthetic result was not
compromised. No other in ections have been noted since that time.
T e complications associated with at gra ing to the breast as described here are similar to or less severe
than those experienced with other breast procedures. With the use o miniscule incisions and the blunt
nature o the technique, the possibility o damage to underlying structures such as nerves, ducts, and
blood vessels is signif cantly reduced. Because no aps are elevated, the chance o skin necrosis is also
extremely unlikely.
Fat trans erred to the breast without access to a blood supply will eventually die. T is can happen a er
almost any surgical breast procedure, whether it is at transposed in a reduction mammaplasty ap or
at inf ltrated into the breast. As in any breast procedure, tissue that is not per used can die and result in
necrotic cysts and even calcif cations.
Four patients in my series12 developed benign-appearing calcif cations that were easily distinguishable
rom cancer, and three patients developed small nodules that revealed at necrosis on aspiration. T ese
abnormalities are similar to those described a er breast reduction,36-40 breast reconstruction,41-44 and
liposuction o the breast.45,46
Whether to augment the existing natural size, correct a congenital de ormity, or restore that which is lost
as a result o disease or trauma, women will always want to eel more attractive, normal, and complete.
T e women in my practice sought to enhance the contour o their breasts using autologous tissue rather

688
Part III • Clinical Applications • Breast: Aesthetic
than, or in addition to, standard alloplastic breast implants. Remarkably natural and long-lasting im-
provements in the size and shape o a breast are possible with a care ul technique o at gra ing. When
harvested and ref ned with minimal trauma and when placed in small aliquots, the transplanted ree at
gra s can remain viable and provide a structure and shape to the breast that cannot be achieved with
implants alone or with other types o surgery.
D i scu ssi on
As previously stated, a er at gra ing to the breast, at necrosis will sometimes occur, calcif cations or
cysts will occasionally result, and lumps will sometimes be palpable, as in every other surgical manip-
ulation o the breast. T e exact incidence o calcif cations a er at gra ing to the breasts remains to be
determined, but the postoperative mammographic changes are similar to those seen with other breast
procedures. In any case, microcalcif cations are not the problem; missing a cancer is the potential prob-
lem a er any surgical procedure to the breast. T ere ore the same vigilance that is used or monitoring
our patients a er any breast procedure should be ollowed a er at gra ing to the breast.
Autologous at gra ing can be used or simple aesthetic augmentation o the breast, correction o breast
asymmetry or breast de ormities, as an adjunct or primary tool in breast reconstruction, and or so
tissue coverage o breast implants. Structural at gra ing using this technique appears to be as sa e as and
perhaps even more e ective than many other methods o changing the contour o the breast. Further
prospective analysis will be necessary to better def ne the indications and results o this technique.
LIMITATIONS
Donor Sites
Most patients f nd it desirable to remove at and contour the rest o the body at the same time as at gra -
ing to the breast. However, a potential complication with this technique is the creation o de ormities at
the donor sites. Even a surgeon who is acile at liposuction may create de ormities, especially when large
amounts o at must be harvested. Moreover, some patients simply do not have adequate donor sites.
T is is especially true in thin patients or patients who have undergone liposuction previously. In these
cases, a combination o at gra ing and implants may be more appropriate.
Large Volume Changes
T e large volume changes commonly attained with implants are not possible using structural at gra -
ing. Even with plenti ul donor sites, o en the maximum change attainable in one session o at gra ing
is an increase o one cup size.
A Dif erent Type o Volume Change
It is di cult to compare the e ect o di usely gra ing a volume o at with the change achieved by plac-
ing an alloplastic implant. With alloplastic implants, a discrete volume is placed into an anatomically
limited space. In the technique or at augmentation described, the surgeon inf ltrates atty tissue di -
usely along the chest wall, beneath the skin envelope, and into surrounding areas such as the sternum
and/or the axilla. Such thoroughly integrated and dispersed ullness does not translate into the same
visual change in volume as the localized change a orded by alloplastic implants. Volume MRI studies or
other volumetric studies may a ord a more accurate quantif cation o the survival o a specif c volume
o at placed into the breast.

689
Chapter 36 • Augmentation o the Breast and uberous Breast
A Longer Procedure
Breast augmentation with structural at gra ing is a much longer procedure than breast augmentation
with alloplastic devices. In such procedures, a pre abricated implant is inserted into a dissected pocket,
requiring a relatively short operative time. Augmentation with structural at is essentially two proce-
dures: a large liposuction and an extensive, di use breast augmentation. T e surgeon must devote time
f rst to harvesting and processing and then placing the at. When operating without another surgeon,
I have o en taken more than hours or a breast augmentation procedure with structural at gra ing.
With two surgeons in a coordinated team approach, it is possible to reduce the operative time. Accord-
ingly, the f nancial cost to the patient must be greater.
ADVANTAGES OF FAT GRAFTING OVER THE USE
OF BREAST IMPLANTS
Fat gra ing has advantages and disadvantages when compared with silicone gel– and saline-f lled breast
implants. Breast augmentation using structural at gra ing obviously avoids implant-related problems,
such as implant leakage or de ation. Breast implants can be visible or palpable with inadequate so tis-
sue cover or with the development o breast capsular contracture. Augmentation with at gra ing in my
experience has consistently created a so , natural-appearing, long-lasting augmentation.
BREAST CANCER DETECTION
T e most important consideration in plastic surgery is the sa ety o our patients. T e li etime probability
o a woman’s developing breast cancer has been estimated to be as high as in .45 Detection and timely
treatment o breast cancer are essential.
For 0 years plastic surgeons rejected at gra ing to the breast because o speculation that transplanted
at might die and cause lumps or calcif cations that would inter ere with detection o breast cancer. T ere
is no evidence that at gra ing should cause greater concern than any other breast procedure. Fat necro-
sis and calcif cations occur in patients with every type o breast surgery: breast biopsy,47,48 implant pro-
cedures,49-54 radiation therapy,46 breast reduction,36,41,55,56 breast reconstruction,37,42,43,57 and liposuction
o the breast.36 T e incidence o calcif cations a er all types o breast surgeries varies, but has been re-
ported to be as high as 0% o patients a er years.37 Fortunately, radiologists are adept at distinguishing
the calcif cations o malignant causes rom the benign calcif cations resulting rom at necrosis.*
Bircoll’s experience63 with more than 00 breast implantations with injected at was positive, and the on-
slaught o lumpy breasts, missed breast cancers, and malpractice suits predicted in never occurred.
His reported incidence o microcalcif cations in was . %.31 Zocchi et al,17 an Italian group with a
large series o at gra ing to the breast, recently reported a similarly low incidence o microcalcif cations;
however, other investigators have reported %64 and 0%.14 A review o my patients demonstrates that at
placed even in small aliquots with each pass can necrose and develop small at cysts and calcif cations.
An accurate incidence o calcif cations a er at gra ing to the breast remains to be determined by uture
studies. However, breast cancer detection remains the sa ety issue, not the incidence o calcif cations.
T ere ore, with any breast procedure, including at gra ing to the breast, patients must be counseled
to obtain regular physical examinations by a physician and annual mammograms and be instructed
on proper breast sel -examination. Every palpable lump should be treated as a possible cancer until
proved otherwise. Although mammography is avored among radiologists or di erentiation o cancer
rom benign lesions o the breast, questionable lesions can also be imaged with ultrasonography65-67
and MRI.49,68 I there is a clinical suspicion or an indeterminate radiologic abnormality, a biopsy should
always be considered.
*Re erences 14, 36, 38, 39, 42-44, 47, 55, 57-62.

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Part III • Clinical Applications • Breast: Aesthetic
BREAST CANCER THERAPY
Although the diagnosis o breast cancer is o paramount importance, the treatment o breast cancer
also must be considered. Women with existing implants who are diagnosed with breast cancer have
signif cantly limited options regarding conservative breast cancer therapies, such as lumpectomies with
radiation.69,70 In the past years, conservative breast therapy has become a standard o care, especially
i the cancer is small.71 Such therapy leaves the patient with a more intact, sensate breast.72 However, i
a saline- or silicone gel–f lled implant is present in a breast in which a cancer is detected, a lumpectomy
may not be a good option. Aesthetic outcomes cannot be ensured without removing the implant and
per orming a mastectomy.69,72,73
Radiotherapy is a critical component o breast conservation treatment to reduce the incidence o lo-
cal recurrence.69,71,74 Un ortunately, radiotherapy o a breast with a saline- or silicone gel–f lled implant
markedly increases the incidence o breast capsular contracture, in ection, extrusion, and a poor cos-
metic result.69,73,75-78 Breasts that have been augmented with structural at gra ing may allow the breast
surgeon to consider conservative breast cancer procedures that are precluded by the use o implants.
With urther studies and experience, at gra ing to the breast may provide a sa er option or our patients
than breast implants in terms o cancer detection as well as cancer treatment.
BREAST RECONSTRUCTION CONSIDERATIONS
A er mastectomy, breast reconstruction with both autogenous aps and with expansion and alloplas-
tic implants can still leave the patients noting subtle de ormities and def ciencies, making their recon-
structions seem incomplete.79 Gra ed at can provide missing coverage18,24-26 and may relax the breast
capsule.18 It can be gra ed in either large or small volumes to correct otherwise di cult problems16,23,64
such as axillary def ciencies, poor breast shape, visible implant edges, capsular contracture, and it can
even treat radiation damage.18 In act, Delay et al15 reported at gra ing to be among the most signif cant
advances in prosthetic breast surgery.
C oncl u si on
One hundred years ago, Halsted denounced breast reconstruction because it might inter ere with the
detection o local recurrences or even cause the progression o breast cancer.80 Because o Halsted, breast
reconstruction was proscribed in the United States or decades. Yet with advances in breast surgery and
radiography, breast reconstruction has become the standard o care ollowing breast cancer procedures.
Almost years ago, one American committee decided that surgeons worldwide should not gra at
to the breast because at gra ing might do something that every other surgical procedure to the breast
does—cause scarring or calcif cations. T e unsupported opinions and statements o the authors o the
ASPRS Position Paper on Fat ransplantation created a double standard whereby at gra ing to the
breast was singled out to be dangerous or possessing the same limitations as every surgical breast pro-
cedure. T is American declaration e ectively censored worldwide discussion o at gra ing to the breast
rom until . T is ban restricted breast augmentation to commercial alloplastic implants and
denied surgeons and women the consideration o this autologous, potentially more e cacious alterna-
tive and adjunct to many breast procedures. It is time to end the prohibition o at gra ing to the breast
created by the position paper. We should judge at gra ing to the breast with the same caution and
enthusiasm that we do with all other breast procedures.

691
Chapter 36 • Augmentation o the Breast and uberous Breast
T ech ni ca l P ea rl s
• In the breast, inf ltration o at should be per ormed in tiny aliquots o about ⁄5 cc or smaller.
• T e volumes o inf ltration necessary to create shape changes must be planned preoperatively.
• Di use inf ltration o at rom the axilla to the sternum and down to the in ramammary old creates a
di erent e ect o a specif c volume than when a silicone breast implant is used.
• T e midline o the sternum should not be crossed with a cannula.
A video relevant to this topic can be found in the Video Contents list on p. xxvi.
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Chapter 36 • Augmentation o the Breast and uberous Breast
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Fat Gr a t ing or Br east
Augment at ion in Asians
Fa-Cheng Li, Lee L.Q. Pu
T h b p q b c d ly A , p -
c lly Ch . Al h h b w h pl h p p l c -
c b y, f c p c p A h p b c
h y w y b l h b dy. M v , h b pl l
c d w h c d k c c l c pl c d b h ly ( c d
c p ) d d l y d dv c (c p l c c , l c l k , d c
).
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w h pl , p d w h j c bl l .
A d 00,000 p d w b w h j c p ly c yl-
d hyd l (A z G l). H w v , cl c l A z G l h b p h b d by
h Ch v c Ap l 200 , d c p h b h b . I
w d h h l c ld c v c pl c , cl d b c
d ch c p c l d c d by f l .
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by y pl c w ldw d . T ch q h b d c
l -l h c b z , h p , d x . Zh l, Ill z d S d ,
C l d S b , d h h h v p d h c v h d
b h p . M A w d w xc v c
h b v l , b h d l, d l . T b
w h , wh ch c b b dy c lp d ll- z d b , y
b h b p y A w . I h ch p , w p q xp c
b A , cl d p c l c d , d c ,
p d c l ch q , d cl c l c .
C h a p t e r 3 7
695

696
Part III • Clinical Applications • Breast: Aesthetic
M
a teri a l a n d M
eth od s
SPECIAL CONSIDERATIONS
Fig. 37-1
Scarring can be a serious problem that limits a patient’s clothing choices i the incisions or liposuction
are not placed in areas that will be hidden by clothes. In this patient, the scars in her back and thighs are
still visible 2 years af er a at graf ing procedure.
Asian women have special characteristics that need to be considered when a surgeon per orms at graf -
ing or breast augmentation. T ese patients are usually thin and small, with proportionally smaller
breasts. T e area to be liposuctioned should be large enough to provide adequate at to ensure an ob-
vious increase in breast volume. T ere ore circum erential liposuction o the trunk or thigh is of en
required. As stated, because o possible poor scar ormation, incisions or liposuction and at graf ing
need to be placed in the hidden areas. Asian women are more likely to orm hypertrophic scars than
Caucasian women.
INDICATIONS
Fat graf ing is more appropriate or women who desire only moderate breast augmentation or those
who simply want to restore their previous shape o the breast af er weight loss, pregnancy, breast eeding,
ptotic breasts as a result o aging, tuberous breast de ormity, severe asymmetry, or simply implant-to- at
conversion. Fat graf ing is also recommended or women who wish to obtain more natural results with
no sense o a oreign body in their breasts.
It is prudent to consider baseline breast mammography, ultrasound, and MRI evaluation be ore lipoin-
jection.

697
Chapter 37 • Fat Gra ting or Breast Augmentation in Asians
DONOR SITE SELECTION AND PREOPERATIVE MARKING
Fig. 37-2
Areas or liposuction and at gra ing to the breast are marked with the patients in the upright position.
Typical areas or liposuction include the abdomen, anks, trochanteric region, inner thigh, the medial
aspect o the knees, and the upper arms, depending on the patient’s natural body at distribution.
No clear correlation has been shown between the donor site location and the longevity o the implanted
at; thus the donor site can be selected based on identif cation o the region with su cient adipose tissue
or even on the patient’s pre erence. We pre er to per orm circum erential abdomen liposuction at the
f rst session o at gra ing and circum erential liposuction o the thighs i there is a second session.
For circum erential abdominal liposuction, entrance incisions are needed or liposuction o the anterior
abdomen and ank; one is placed in the pubic hairline, another in the umbilicus, and the third in the
intergluteal old or liposuction o the ank in the prone position. For circum erential thigh liposuction,
two 0.4 cm incisions are placed near the pubic hair above the inguinal old or liposuction o the anterior
aspect o the thigh, and two incisions are placed in the in ragluteal old (in the perpendicular line rom
the tubercle o the ischium) or liposuction o the posterior aspect o the thigh.
ANESTHESIA
Because signif cant quantities o at are required or breast augmentation, the liposuction area usually
needs to be large, so we per orm the procedure with the patient under intravenous sedation through the
tumescent technique.
INCISIONS FOR FAT HARVESTING
Incisions are made in the donor sites using a No. 11 blade. For abdominal at harvesting, two incisions
are made: one in the middle o the pubic hairline and one in the umbilicus. For harvesting o at rom the
thighs, an incision is made in each subgluteal old or liposuction o the posterior area, and an additional
incision is made near the pubic hair above the inguinal old or liposuction o the anterior area o the
thigh and medial area o the knee. I there are any previous scars in the donor sites, they certainly can be
used as the incision sites.

698
Part III • Clinical Applications • Breast: Aesthetic
Fig. 37-3
o prevent skin abrasion at the incision, be ore liposuction a skin protector made rom a 1 cc syringe is
inserted into the incision and secured with sutures.
HARVESTING AND PROCESSING
Fig. 37-4
A er intravenous sedation has been administered, the harvest sites are inf ltrated with tumescent solu-
tion (20 ml o 2% lidocaine with epinephrine, 1:100,000/L o normal saline solution). T e at is aspirated
using a three-holed blunt cannula (with a 2.5 to 3 mm inner diameter) connected to a suction machine
with low negative pressure (–400 mm Hg). T e processing procedure we use to prepare at or injection is