Fat Injection From Filling to Regeneration

700
Part III • Clinical Applications • Breast: Aesthetic
2 mm o a blood supply will survive, but at placed beyond that distance will undergo necrosis and will
eventually be replaced by f brous tissue, so bolus injection o at gra s should always be avoided. T e at
is placed in multiple planes and multiple tunnels rom deep to subcutaneous tissue. Approximately two
thirds o the collected at is injected layer by layer into the submuscular plane, the retroglandular plane,
and the intraglandular space. T e remaining one third o at is injected into the subcutaneous space. T e
goal is to inject approximately 25 cc to 3 cc o at per session and per breast, depending on the avail-
ability o at and the patient’s habitus, such as her existing breast size and skin elasticity. A er injection,
the injected area can be care ully and gently molded and reshaped to achieve the desired shape o the
breast. No dressing is used on the breasts postoperatively to avoid direct pressure on the breasts.
R esul ts
A total o 628 patients were involved in our series conducted rom July 2 2 to August 2 13, o whom
45% underwent one session o at gra ing, 5 % required two sessions, and 5% required three sessions
to achieve optimal results. An average o 2 cc o at was gra ed per breast at each session (range 12
to 4 cc). T e average clinical ollow-up was 18 months (range 6 to 2 months). In most patients their
breast size was signif cantly improved.
Fig. 37-6
T is 21-year-old girl requested breast augmentation. She did not want breast implants and had previ-
ously undergone breast augmentation with at gra ing by another surgeon. However, her results were
disappointing. We per ormed at gra ing with 22 cc o processed at per breast, harvested rom the
thighs. At 8-month ollow-up, her breast size had increased dramatically, and they elt natural and so .

701
Chapter 37 • Fat Gra ting or Breast Augmentation in Asians
Fig. 37-7
T is 2 -year-old woman sought breast augmentation. Because she requested signif cantly larger breasts,
two sessions o at gra ing were per ormed, in which 28 cc and cc, respectively, were injected into
each breast, with an interval o 6 months. She is shown 2 months postoperatively with excellent results.
Her enlarged breasts eel natural and so . T ere are no palpable nodules and no calcif cation.

702
Part III • Clinical Applications • Breast: Aesthetic
Fig. 37-8
T is 1-year-old girl had major breast asymmetry and moderate mammary hypertrophy o the right
breast, with some degree o ptosis. We per ormed right breast reduction by per orming liposuction o
cc o at, and we per ormed at graf ing to augment the lef breast with cc, harvested rom the
abdomen. Good symmetry is evident months af er the procedure.

703
Chapter 37 • Fat Gra ting or Breast Augmentation in Asians
Fig. 37-9
T is 44-year-old woman presented with mammary hypotrophy a er breast eeding. We per ormed at
gra ing or breast augmentation. In the f rst session, 26 cc o processed at rom the arms and back was
placed in each breast. A second session was per ormed months later, with 6 cc o at harvested rom
the trochanteric area and injected into each breast. Her results at 11 months a er the second procedure
are quite satis actory. Preoperative and postoperative 1-weighted MRIs reveal that the transplanted at
survived well and ormed thick layers in the subcutaneous, retroglandular, intramuscular, and retromus-
cular planes.

704
Part III • Clinical Applications • Breast: Aesthetic
C om p l i ca ti on s
Several early and late postoperative complications o at gra ing or breast augmentation have been de-
scribed, including localized in ection o the harvest or injection site, sepsis, at resorption and necrosis,
calcif cation, ormation o sclerotic nodules and granulomas, and a less than optimal outcome. Compli-
cations rom this procedure are generally rare, but they are even less common and less severe than those
observed rom other breast operations.
For the donor site, this procedure has the same potential sequelae as that o a normal liposuction proce-
dure, such as pain or about 8 hours, which can be well controlled with simple analgesics. Ecchymosis
may persist or 3 weeks, and the postoperative edema resolves on average in 3 months. For the breast,
the ecchymosis persists or 1 to 15 days, and the edema resolves in about 1 month. Breast volume is
generally stable 3 to months a er surgery. T e patient must be adequately in ormed that there will be
progressive loss o breast volume within the f rst 3 months a er surgery.
Fat gra ing may result in varying degrees o nodule or cyst ormation and calcif cation associated with
necrosis o the injected at tissue. T is can occur as a result o excessive at gra ing into an area already
saturated with at, with subsequent ischemic necrosis o the injected tissue.
In our series, one patient developed a deep in ection a er breast augmentation with at gra ing. T e
in ection resolved a er drainage, irrigation, and administration o oral antibiotics. Nevertheless, her
aesthetic result was not compromised. wo patients developed benign-appearing calcif cations that were
easily distinguishable rom cancer. T ree patients developed small nodules that revealed at necrosis on
aspiration.
D i scu ssi on
We ound that volume maintenance a er lipotrans er or breast augmentation correlated well with the
total amount o injected at. I the volume o the at transplanted into the breast is less than 15 cc on
each side, the result will be disappointing. T ere ore, in our opinion, at gra ing or breast augmentation
is not suitable or very thin women who have insu cient at deposits. Signif cant cosmetic improvement
was achieved through two or three sessions o at gra ing in patients with adequate adipose tissue, even
i their breasts are very small. Interestingly, we ound that when patients received a second session o at
gra ing, the cosmetic result was enhanced signif cantly. T is may be attributed to the increased vascu-
larization that resulted rom survival o the previously transplanted at.
T e method we used is associated with a Chinese traditional philosophy—the “Golden mean,” which is
Con uscius’ philosophy. In addition to striving to achieve a natural, proportional breast or each patient,
it means that we must achieve the best balance between a minimally invasive approach and the least
ischemic time o the at be ore it is transplanted into the breast. Everything has two aspects; we choose a
point that achieves the best balance to achieve the maximal results. It is reported that most o adipocytes
in aspirate preserved at room temperature beyond ° C will undergo signif cant damage. T e whole pro-
cess o at gra ing should be per ormed as quickly as possible.
Syringe liposuction using smaller syringes (1 cc) with minimal negative pressure is considered to be the
standard technique or harvesting o at. However, this technique is time consuming when collecting a
large volume o at. T ere ore we use a suction machine with low negative pressure (– mm Hg) or at
harvesting in an e ort to reduce the liposuction time.
A gra ed at parcel that is too large in volume may su er central necrosis in vivo because o a lack o
adequate nutrition di usion and ailure o neoangiogenesis. Minimizing the amount o at gra ed with

705
Chapter 37 • Fat Gra ting or Breast Augmentation in Asians
each pass o the cannula during injection will maximize the sur ace area o contact between the gra ed
at and the recipient tissue. Coleman’s technique o at gra ing has been popularized and is known to
many surgeons, which emphasizes an atraumatic method o at harvesting, proper centri ugation, and
miniscule parcels in each injection, aimed at maximal contact between transplanted at and recipient
tissue. However, or breast augmentation, this process takes approximately hours to place 2 cc into
one breast. T e negative e ects o extracorporeal ischemic time potentially outweigh the benef t o the
technique o minimal trauma to at or injection. o enhance the e ciency o at injection while reduc-
ing the ischemic time, we use a 2 cc Luer-Lok syringe or at injection in which 2 cc o at contained
in one syringe can be meticulously injected in 1 minute, still in accordance with the principles proposed
by Coleman.
C oncl u si on
Remarkable, long-lasting, natural improvements o the breast’s size and shape can be achieved with at
gra ing in most patients. T e more painstaking the attention to details o at harvesting, processing,
and injection, the better the clinical outcome. Several important issues include low pressure but e cient
technique in harvesting at; condensing the lipoaspirate with a cotton pad a er gentle washing and f l-
tering; multilayered placement o at; and reduction o ischemic time. All these actors are critical to the
success o at gra ing to the breast. A good to excellent result rom our patient series demonstrates the
value o at gra ing or breast augmentation in Asian women.
RECOMMENDED READING
Cheng MH, Huang JJ. Augmentation mammaplasty in Asian women. Semin Plast Surg 2 :48, 2 9.
Coleman SR, Saboeiro AP. Fat gra ing to the breast revisited: sa ety and e cacy. Plast Reconstr Surg 119: ,
2 .
Del Vecchio D, Rohrich RJ. A classif cation o clinical at gra ing: di erent problems, di erent solutions. Plast
Reconstr Surg 1 : 11, 2 12.
Del Vecchio DA, Bucky LP. Breast augmentation using preexpansion and autologous at transplantation: a
clinical radiographic study. Plast Reconstr Surg 12 :2441, 2 11.
Eremia S, Newman N. Long-term ollow-up a er autologous at gra ing: analysis o results rom 116 patients
ollowed at least 12 months a er receiving the last o a minimum o two treatments. Dermatol Surg
26:11 , 2 .
Gutowski KA; ASPS Fat Gra ask Force. Current applications and sa ety o autologous at gra s: a report o
the ASPS Fat Gra ask Force. Plast Reconstr Surg 124:2 2, 2 9.
Hyakusoku H, Ogawa R, Ono S, et al. Complications a er autologous at injection to the breast. Plast Recon-
str Surg 12 : 6 ; discussion 1, 2 9.
Illouz YG, Sterodimas A. Autologous at transplantation to the breast: a personal technique with 2 years o
experience. Aesthetic Plast Surg : 6, 2 9.
Khouri RK, Eisenmann-Klein M, Cardoso E, et al. Brava and autologous at trans er is a sa e and e ective
breast augmentation alternative: results o a 6-year, 81-patient, prospective multicenter study. Plast Re-
constr Surg 129:11 , 2 12.
Kuran I, umerdem B. A new simple method used to prepare at or injection. Aesthetic Plast Surg 29:18;
discussion 2 , 2 .
Kwak JY, Lee SH, Park HL, et al. Sonographic f ndings in complications o cosmetic breast augmentation with
autologous at obtained by liposuction. J Clin Ultrasound 2:299, 2 4.
Li FC, Chen B, Cheng L. Breast augmentation with autologous at injection: a report o 1 cases. Ann Plast
Surg (Suppl 1):S , 2 14.
Maillard GF. Liponecrotic cysts a er augmentation mammaplasty with at injections. Aesthetic Plast Surg
18:4 , 1994.

706
Part III • Clinical Applications • Breast: Aesthetic
Peer LA. Loss o weight and volume in human at graf s: with postulation o a “cell survival theory.” Plast
Reconstr Surg 5:21 , 195 .
Pulagam SR, Poulton , Mamounas EP. Long-term clinical and radiologic results with autologous at trans-
plantation or breast augmentation: case reports and review o the literature. Breast J 12: 3, 2 .
Rohrich RJ, Sorokin ES, Brown SA. In search o improved at trans er viability: a quantitative analysis o the
role o centri ugation and harvest site. Plast Reconstr Surg 113:391; discussion 39 , 2 4.
albot SG, Parrett BM, Yaremchuk MJ. Sepsis af er autologous at graf ing. Plast Reconstr Surg 12 :1 2e,
2 1 .
Ullmann Y, Shoshani O, Fodor A, et al. Searching or the avorable donor site or at injection: in vivo study
using the nude mice model. Dermatol Surg 31:13 4, 2 5.
Valdatta L, T ione A, Buoro M, et al. A case o li e-threatening sepsis af er breast augmentation by at injec-
tion. Aesthetic Plast Surg 25:34 , 2 1.
Wang Y, Qi K, Ma Y, et al. [Fat particle injection auto-transplantation: a 1 year review] Chin J Plastic Surg
18:95, 2 2.
Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotrans er or cosmetic breast augmentation: supportive use
o adipose-derived stem/stromal cells. Aesthetic Plast Surg 32:48, 2 8.
Zheng DN, Li QF, Lei H, et al. Autologous at graf ing to the breast or cosmetic enhancement: experience in
patients with long-term ollow up. J Plast Reconstr Aesthet Surg 1: 92, 2 8.
Zocchi M, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg 32:313, 2 8.

707
C h a pt e r 3 8
A
l h h h c c c b (CBA) l , h v l -
z d ch b . CBA c b h dv d v l -
h c v d d b l w h h q , wh ch k
bl c h b h d d. N l d h b f b b h
h v l l d c l , b l d v h c c
dv l c l h b d h h v l .
A w ll , h ch ll bl w h h b
l h v d q c v h d l l . P v l h
w dd d b b c l l c l . H w v , CBA bl c l -
l l c , w h c h l d d b . T v d h ll
c d w h b c l l , ch h h c d c h , , d -
h l w h c v .
I ll d c b d CBA 9 F ch bl c .1 S b q l I d l d h c c
d ll d c d h composite breast augmentation.2 I 5 h v w
CBA w bl h d d c b l h c b .3,4
T ch w ll l h l c CBA h c b , dd l
h c h l c b d v w c d h c
c . I d h c h ch dd CBA h c c c l l-
ch P l d d .
Pr imar y Composit e Br east
Augment at ion
U l , b l w l c d b c l . F h , b c
h l c l w b d ch c F c d h U d S
l 6 , ll l d h w l f ll d. S v l bl w c d
w h b c l l : c d c d c h , wh ch b q l l d
Composit e Br east
Augment at ion
Eric Auclair

708
Part III • Clinical Applications • Breast: Aesthetic
increased capsular contracture rates (reported to be up to %); increased pain noted by the patient or
several days postoperatively; dynamic activity o the implant; and an appearance o “bottoming out and
down” in a concerning number o patients.
T e introduction o new-generation cohesive silicone gel implants resulted in prostheses with improved
shell coverage and reduced silicone bleed. Surgeons rapidly observed a signif cant decrease in the ap-
pearance o rippling, and we were able to use anatomic shaped implants. T is resulted in the introduc-
tion o premuscular, sub ascial implant positioning, as described by Gra et al5 and Góes and Landecker.6
T e f rst presentation by Delay et al7 at a French Congress in 2 introduced the use o isolated at
gra ing or aesthetic breast augmentation. Since this revelation, breast surgeons have begun to use at
gra ing in combination with implants to improve aesthetic outcomes, particularly in thin patients with
inadequate so tissue coverage.
M
a teri a l a n d M
eth od s
Be ore one can embark on any surgical procedure, appropriate patient selection must take place. T is
includes assessment o medical conditions such as diabetes and coagulation disorders and whether the
patient is a smoker. In addition, we do not recommend at gra ing in patients with a personal or amily
history o breast cancer. During the consultation, patient expectations and desires in terms o volume
and shape o the breasts must be discussed.
Clinical examination is especially important in an aesthetic breast patient. In particular, the ollowing
should be noted:
• Symmetry o the areolas, level o the in ramammary olds, and volume o the mammary glands
• Preexisting rotation o the chest rom scoliosis or pseudoscoliosis; ailure to recognize this will
result in obvious breast asymmetries
• Breast base diameter, which helps to determine prosthesis selection
• Nipple-to-clavicle distance (this is typically 14 to 1 cm, depending on the patient’s height)
• Areola-to-in ramammary old distance to help in selecting an appropriately shaped implant ( or a
natural-appearing result, this distance should be at least cm)
Following patient selection, one must select an appropriate implant. CBA allows the surgeon to sculpt
the shape o the breast through the use o at gra ing. Subsequently, specif c anatomic implants are less
requently used. In other words, round implants can be used in the overwhelming majority o cases,
thus avoiding the consequences o implant rotation, while the anatomic shape can be provided with the
addition o at gra ing. In my practice, be ore the introduction o CBA, anatomic implants were used in
% o cases, whereas now we use them in ewer than 1 %. Approximately 1 % o patients will present
with a reduced areola-IMF distance o less than 3 to 4 cm, and in these women, anatomic implants are
recommended.
In selecting the correct implant, one must consider both the breast diameter and the desired breast
projection. Projection corresponds to the desired cup size; breast diameter is measured by determining
the expected breast width. o appreciate the implant volume required to achieve a certain cup size, it is
use ul to know that or a given patient who presents with an A cup, an implant projection o 3 cm will
result in a B cup, a cm implant projection will convert to a C cup, and a 4 cm projection will provide
the patient with a result in between the two.

709
Chapter 38 • Composite Breast Augmentation
T e CBA procedure is per ormed with the patient under general anesthesia. She is initially positioned
according to which areas have been determined as harvest sites or lipoaspirate. For example, i at is to
be harvested rom the buttocks or posterior thighs, the patient will initially be in the prone position.
I su cient at can be attained rom the abdomen or anteromedial thighs, the entire procedure can be
per ormed with the patient in the supine position.
T e inf ltrate or analgesic and liposuction purposes should contain a long-acting analgesic (lidocaine)
and epinephrine, mixed in normal saline solution. T e at is then harvested using a or 4 mm diameter
cannula. T e resulting lipoaspirate is washed and decanted, then distributed among 1 cc syringes or
later inf ltration.
Preparation or implant insertion can now take place. I use a transaxillary approach, so the patient is
positioned with her arms in 4 degrees o shoulder abduction and degrees o elbow exion. T e use
o arm boards may be required.
A 4 to cm L-shaped incision is made in the hair-bearing skin o the axilla, and a thick ap o skin and
subcutaneous at is elevated. T e lateral border o the pectoralis major muscle is identif ed a er care ul
dissection. T e premuscular sub ascial plane can then be entered and the implant pocket created, as
described by Gra et al5 and Góes and Landecker.6 An illuminated retractor is use ul during pocket dis-
section because it allows visualization at all times. T is ensures adequate hemostasis as well as accurate
assessment o the dimensions o the pocket.
o ensure aseptic conditions, surgical gloves are changed immediately be ore the implant is placed. T e
implant is handled or a minimal time and is bathed in an antibiotic solution (gentamicin).
T e operation concludes with multilayered wound closure. Fascia is closed with a - monof lament
suture, the subcutaneous layer with a 4- slow-resorbing suture, and the intradermal layer with a rapidly
resorbing 4- suture.
At this stage, at gra ing may commence. T e goal is to camou age the borders o the implant, especially
the superior and medial borders, which might otherwise be visible in thin patients. A stab incision in
the medial aspect o the IMF and another in the superomedial edge o the areola allow su cient access.
Gra ing is per ormed in a radial direction in the subcutaneous plane. Care must be taken not to violate
the implant pocket. T e cannula used or these injections is 1 cm long and 1.2 mm in diameter. T e
details o at transplantation are summarized in able -1.
Table 38-1 Details of Fat Transplantation
Average amount harvested (range)
cc (1 to 2 cc)
Average amount injected (range)
12 cc (1 to 2 cc)
Number o procedures per ormed

1
A compressive bandage is applied and worn overnight. It is then replaced the ollowing day with a med-
ical bra that is to be worn continuously or weeks to ensure maximal engra ing o at and to maintain
implant position.

710
Part III • Clinical Applications • Breast: Aesthetic
R esul ts
Fig. 38-1
T is is a superior intraoperative view o a patient undergoing CBA. One can see the power ul ef ect o
at gra ing on the right breast; the contours o the implant are not visible, and the breast’s contour and
cleavage are improved.
Fig. 38-2, A-D
Preoperative
A

B
1 year postoperatively
C
D
T is 28-year-old patient presented with obvious breast hypoplasia. She underwent breast augmentation
with 24 cc round implants placed bilaterally in a sub ascial plane through a transaxillary approach. In
addition, cc o at was gra ed into each breast.

711
Chapter 38 • Composite Breast Augmentation
Fig. 38-2, E-H
2 years postoperatively
E
F
G
4 years postoperatively
H
One can appreciate the stability o these results at , 2, and 4 years postoperatively, with no urther lipo-
f lling required over this period.
T e reasons only 0% o cases are appropriate or at-only augmentation are two old: ( ) the necessity
o harvesting at least L o at to provide su cient at to augment breast volume, and (2) an inability to
provide more than a one-cup increase in size when harvest site volumes would be inadequate. Although
the typical patient presenting or breast augmentation has a slender physique, a low BMI is not a contra-
indication or CBA. In act, only 200 cc o at is required to camou age implant visibility and improve
breast shape, as can be seen. One o the most noteworthy benef ts o CBA is the concomitant liposculp-
ture, a side e ect welcomed by patients.

712
Part III • Clinical Applications • Breast: Aesthetic
Fig. 38-3
T is patient had a signif cant weight loss o 50 kg that led to breast atrophy, ptosis, and skin excess. She
underwent CBA in which 360 cc round implants were placed, and 0 cc o at harvested rom the thighs
was gra ed in each breast. She is seen year postoperatively. CBA is particularly use ul in augmentation
mastopexy, where skin tightening is one o the main goals o the operation, the second aim being to
provide volume. T rough the use o at gra ing in the subdermal layer, CBA allows skin tightening by
providing additional coverage between the implant and skin.
Between 006 and 0 3, we per ormed CBA on 99 patients. T e data obtained rom this group o pa-
tients are summarized in ables 38- and 38-3.
Table 38-2 Patient Demographics
otal number

99
Age (average, range), years

35 ( 0 to 6)
Weight (average, range), kg

53. (45 to 65)
BMI (average, range)

8.9 ( 6 to )
Table 38-3 Implant Characteristics
Implant volume (average, range)

0 cc ( 50 to 850 cc)
Round

00
Anatomic

99

713
Chapter 38 • Composite Breast Augmentation
C om p l i ca ti on s
T e most common complication o CBA is the need or additional at gra ing. In a minority o cases,
capsular contracture has been observed (Baker classif cations 2 and ). However, capsular contracture
is a known complication o any implant procedure. able - outlines the number o complications
observed in our series o 99 CBA procedures.
Table 38-4 Complications
Capsular contracture

2
Additional at gra ing required


Hematoma


In ection

0
D i scussi on
In our practice, 0% o patients who request breast augmentation undergo CBA. A urther 50% will re-
ceive an implant-only augmentation, while the remaining 0% undergo at gra ing augmentation only.
Since the introduction o CBA, breast volumes are being more requently enhanced with at, and the use
o silicone is ollowing a downward trend.
When we began per orming CBA, more than 5% o the implants we used were shaped; today shaped
implants have almost disappeared rom our practice. Instead, at gra ing enables the almost universal
use o round implants, allowing one to shape the breasts accordingly. T is avoids the complication o
malrotation that is o en seen with anatomic implants.3
C oncl usi on
A concern with CBA that must be addressed is the potential e ect o transplanted at adjacent to im-
plants and whether this impairs the interpretation o mammographic screening. A recent publication
by Cameron et al4 addressed this specif c question. In their study, 52 women who had undergone CBA
had their preoperative/postoperative mammograms reviewed by three radiologists. A total o 5 mam-
mograms were reviewed, with an average ollow-up o 29 months (range 6 to 2 months). T e results o
this study showed that no additional imaging or biopsies were recommended by any o the radiologists.
Furthermore, all mammograms were assigned a BI-RADS assessment category 2, indicating benign pa-
thology. T is suggests that CBA is a sa e procedure and does not impair postoperative surveillance o
breast malignancy.

714
P III • Cl l A l • B : A h
Secondar y Composit e Br east
Augment at ion
O h h h w wh b v w l -
w , l 25% l . T f q l ,
b l . A q , b h v l h
b b . T b h b h b x b k l l
b , h h h b G .8
M
a teri a l a n d M
eth od s
I 20 3 w b h F h S Pl
R v S .9 T l 00 wh w b w
M h 200 D b 20 2. T v w 3 .5 ( 20 6 ). T v
BMI w .05 ( 6 23). O h , 0% w l w h h l , q
b v l .
T b b h , l b , w ll w :
• I l v b l
%
• I l
6 %
• N l l
%
• A
3%
• C
30%
• A l v
25%
• P
22%
• R , bl l
6%
h , h l h q l l h ll w :
• F
00%
• C l l
30%
• Ch l k
25%
• M x
5%
• C l
6%
• I l l
0%

715
Chapter 38 • Composite Breast Augmentation
R esul ts
As noted, at gra ing was used in all cases. T e amount o at used, as well as the areas o at inf ltration,
were as ollows:
• Average volume o at gra ed
2 cc (range 0 to 00 cc)
• Zones
– Cleavage
9 %
– Lateral breast
%
– Lower pole
%
– Anterior sur ace
4%
• Average volume o liposuction 40 cc (range 200 to 000 cc)
Fig. 38-4
T is patient requested secondary breast augmentation. She had obvious breast asymmetry and her im-
plants were visible; there was capsular contracture in the le breast. In addition, she had a signif cant loss
o cleavage, with a hollow presternal area. Management o this patient involved pocket symmetrization,
implant exchange, and subcutaneous at gra ing o the entire anterior aspect o the breasts. She is seen
years postoperatively with a satis actory and stable result.

716
Part III • Clinical Applications • Breast: Aesthetic
C om p l i ca ti on s
Lost to
follow-up
5
4
3
2
1
< 1
0
5
10
15
20
25
30
Percentage
Y
e
a
r
s
Fig. 38-5
T e interval rom secondary augmentation to the last ollow-up visit in our series is summarized.
Fig. 38-6
Satisfied
Retouched
Contracture
Ptosis
Lost
9%
9%
10%
65%
6%
Our results and complications re ect an average ollow-up o 2 years, with a maximum o 5 years; 20%
o patients were observed or 3 years, and only % were lost to ollow-up. T is represents a signif cant
period o postoperative observation. T e signif cance o these long ollow-up periods is that it attests to
the longevity o the results o CBA and the low associated complication rate.

717
Chapter 38 • Composite Breast Augmentation
Although most patients (65%) who underwent CBA or secondary breast surgery were pleased with
their result, a small proportion o women required urther surgery. Some o the problems encountered
included residual contracture and ptosis. In the small group with ptosis ( %), these patients specif cally
requested that they not have any vertical removal o skin excess. Keeping this in mind, their breast ptosis
could not be adequately treated. Not in requently ( %), minor irregularities needed to be addressed with
urther at gra ing.
With regard to the recurrence o capsular contracture, we f nd that the addition o at gra ing signif -
cantly reduces the reappearance o capsule ormation. However, this is a subjective observation that
requires urther investigation.
Another option or improving so tissue cover in secondary cases is the use o acellular dermal matrix
(ADM). T is has been well described in several papers.10-13 T e purpose o ADM is to rein orce so tis-
sue in patients who typically have reduced coverage. In particular, in patients presenting with capsular
contracture, ADM is used ollowing capsulectomy to strengthen the subsequently weaker tissue. Al-
though the use o ADM in breast reconstruction has demonstrated low rates o capsular contracture ( %
to . %),14-19 its role in aesthetic breast surgery has yet to be conf rmed, it certainly represents a valuable
tool.
D i scussi on
It is clear that there is a considerable demand or secondary breast augmentation. T e most common
indications, alone or in combination, are implant visibility, asymmetry, and movement with animation.
CBA provides a power ul tool or addressing these problems through two mechanisms: ( ) it creates a
more physiologic situation in which the implant can be placed in a sub ascial site, and (2) the addition
o at gra ing improves so tissue coverage o the implant, resulting in a ar more natural appearance o
the breasts.
C oncl usi on
From our experience with the use o at gra ing in combination with breast implants over the past
years, we have noticed not only a change in surgeons’ expectations, but also that o patients. T is
valuable technique o ers several unique advantages. First, it enables the surgeon to avoid submuscular
placement o implants, thus avoiding the associated complications o pain and animation on movement.
Furthermore, this technique is still viable in very thin patients, since less than 2 cc o at is required
or both breasts.
T e second advantage o ered by CBA is the ability o at gra ing to biologically alter the properties o
the skin envelope and surrounding tissues. T is e ect is especially interesting to observe in cases o aug-
mentation mastopexy, where the transplanted at can improve the issues o skin excess and striae.
T ird, CBA has an important role in secondary cases o breast augmentation. T ese patients typically
present with de ects in their so tissue coverage. Gra ed at is an ideal tool to address this problem. An-
other option in these cases is the use o ADM, which certainly has its merits. It should be remembered
that both CBA and ADM can in act be used in conjunction with each other to improve outcomes.
We now hope to urther investigate the role o at gra ing in the prevention o capsular contracture. By
examining the biologic e ects o at and stem cells on capsule ormation, perhaps we can gain a better
understanding o how to address the challenging problem.

718
Part III • Clinical Applications • Breast: Aesthetic
ACKNOWLEDGMEN
I would like to acknowledge the assistance o Dr. Namrata Anavekar in the writing o this chapter.
REFERENCES
. Auclair E. [Benef t o complementary lipof lling in aesthetic breast augmentation with implant] Ann Chir
Plast Esthet 54:49 , 2009.
2. Auclair E, Blondeel P, Del Vecchio DA. Composite breast augmentation: so tissue planning using im-
plants and at. Plast Reconstr Surg 32:55 , 20 3.
3. Auclair E, Anavekar N. Combined use o implant and at gra ing or breast augmentation. Clin Plast Surg
42:30 , 20 5.
4. Cameron JA, Auclair E, Nelson M, et al. Radiologic evaluation o women ollowing cosmetic breast aug-
mentation with silicone implants and at gra ing. Plast Reconstr Surg 34(4 Suppl ):9 , 20 4.
5. Gra RM, Bernades A, Ripple R, et al. Sub ascial breast implant: a new procedure. Plast Reconstr Surg
:904, 2003.
6. Góes JC, Landecker A. Optimizing outcomes in breast augmentation: seven years o experience with the
sub ascial plane. Aesthetic Plast Surg 2 : , 2003.
. Delay E, Gosset J, oussoun G, et al. [E cacy o lipomodeling or the management o sequelae o breast
cancer conservative treatment] Ann Chir Plast Esthet 53: , 200 .
. Grotting J, ed. Reoperative Aesthetic & Reconstructive Plastic Surgery, ed 2. St Louis: Quality Medical
Publishing, 2006.
9. Auclair E. [Contribution o lipo-f lling as part o breast augmentation or aesthetic revisions, about 00
consecutive cases] Presented at the Congrès de la SOFCPRE, Paris, Nov 20 3.
0. Maxwell GP, Gabriel A. E cacy o acellular dermal matrices in revisionary aesthetic breast surgery: a
6-year experience. Aesthet Surg J 33:3 9, 20 3.
. Pozner JN, White JB, Newman MI. Use o porcine acellular dermal matrix in revisionary cosmetic breast
augmentation. Aesthet Surg J 33:6 , 20 3.
2. Maxwell GP, Gabriel A. Revisionary breast surgery with acellular dermal matrices. Aesthet Surg J 3 : 00,
20 .
3. Mof d MM. Acellular dermal matrix in cosmetic breast procedures and capsular contracture. Aesthet
Surg J 3 ( Suppl): S, 20 .
4. Breuing KH, Colwell AL. In erolateral AlloDerm hammock or implant coverage in breast reconstruc-
tion. Ann Plast Surg 59:250, 200 .
5. Zienowicz RJ, Karacaoglu E. Implant-based breast reconstruction with allogra . Plast Reconstr Surg
20:3 3, 200 .
6. Bindingnavele V, Gaon M, Ota KS, et al. Use o acellular cadaveric dermis and tissue expansion in post-
mastectomy breast reconstruction. J Plast Reconstr Aesthet Surg 60: 2 4, 200 .
. Spear SL, Parikh PM, Reisin E, et al. Acellular dermis-assisted breast reconstruction. Aesthet Plast Surg
32:4 , 200 .
. Namnoum JD. Expander/implant reconstruction with AlloDerm: recent experience. Plast Reconstr Surg
24:3 , 2009.
9. Lanier S , Wang ED, Chen JJ, et al. T e e ect o acellular dermal matrix use on complication rates in tis-
sue expander/implant breast reconstruction. Ann Plast Surg 64:6 4, 20 0.

BREAST
Reconstructive
S e c t i o n F i ve

(Trang không có chữ)

Oncol ogic Ris s o Fat Gr a t ing
o t he Br east
Jean-Yves Petit, Mario Rietjens, Pierre Carlo Rey,
Visnu Lohsiriwat, Francesco Bertolini
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721

722
Part III • Clinical Applications • Breast: Reconstructive
the literature is based on a limited number o studies with ew cases, with no control groups, based on
expert opinion or case reports. Although no incontrovertible evidence o an increase in the risk o can-
cer recurrence rom at gra ing has been observed or published, they cannot as yet provide def nitive
recommendations on the cancer risk associated with at gra ing.
T e purpose o our two retrospective studies, conducted at our institute, the European Institute o On-
cology (IEO) in Milan, was to evaluate the oncologic outcome o patients treated or breast cancer by
conservative treatment or mastectomy, with or without radiotherapy and medical treatment, who un-
derwent at gra ing or morphologic improvement o the breast.9,10 T e f rst study involved gathering a
cohort with invasive and in situ types o breast cancer; the second study ocused only on those with in
situ cancers. T ese retrospective studies were matched to groups o patients without at gra ing to com-
pare the risk o locoregional recurrence between the study group and the control group.
M
a teri a l a n d M
eth od s
FIRST STUDY
From the IEO Breast Cancer Database, we selected all the women who underwent surgery between
and 8 or primary breast cancer at the IEO.9 We then identif ed all patients who subsequently under-
went a at gra ing procedure or reconstructive purposes, who had no tumor recurrence between the
primary surgery and at gra ing procedure. We excluded women with synchronous distant metastases at
diagnosis, bilateral or recurrent tumor, previous cancer, and those receiving neoadjuvant treatment. We
thus collected the cases o 3 consecutive patients. For each patient, we selected two matched patients
with similar characteristics who did not undergo at gra ing.
SECOND STUDY
For the second study we selected, in the same population, the patients with in situ cancer and compared
these cases with a matched population ( / ) o in situ patients who did not undergo at gra ing.10 We an-
alyzed 5 intraepithelial neoplasia patients who had undergone at gra ing, with no recurrence between
primary surgery and at gra ing. A control group o 8 matched patients (two controls per at gra ing
patient) with corresponding recurrence- ree intervals was utilized. Both groups were also matched or
their main cancer criteria. A local event (LE) was the primary endpoint, with ollow-up starting rom
the baseline.

723
Chapter 39 • Oncologic Risks o Fat Gra ting o the Breast
R esul ts
FIRST STUDY
Eighty-nine percent o the tumors were invasive. Median ollow-up was 56 months rom the primary
surgery and 6 months rom the at gra ing procedure. Eight and 1 patients had a local event in the
at gra ing and control group, respectively, leading to comparable cumulative incidence curves (p =
0. ; hazard ratio: at gra ing versus no at gra ing = 1.11; 5% conf dence interval 0.4 to .64).
T ese results were conf rmed when patients who had undergone quadrantectomy or mastectomy were
analyzed separately and when the analysis was limited to invasive tumors, no statistical di erence was
seen. Analysis o a subgroup o patients with intraepithelial neoplasia showed a higher risk o locore-
gional recurrence in the study group, especially a er conservative treatment (p = 0.04). Based on
cases, the at gra ing group demonstrated a higher risk o local events when the analysis was limited to
intraepithelial neoplasia.
Fig. 39-1
STUDY 1: CUMULATIVE INCIDENCE OF LOCAL EVENTS:
36 MONTHS—LOCAL, LOCOREGIONAL, LOCAL AND DISTANT
20
15
10
5
0
0
6
12
18
24
30
36
Months from baseline
No lipofilling
Lipofilling
Gray test p value = 0.792
HRfat grafting vs no fat grafting = 1.11 (95% confidence interval 0.47-2.64)
C
u
m
u
l
a
t
i
v
e

i
n
c
i
d
e
n
c
e

(
%
)

724
Part III • Clinical Applications • Breast: Reconstructive
SECOND STUDY
T e median ollow-up in the second study was 6 and 66 months rom surgery, and 8 and rom
baseline, or the at gra ing and control groups, respectively. T e 5-year cumulative incidence o LE was
8% and % (p = 0.0 ). A subgroup analysis showed that at gra ing did not statistically increase the
risk o LE in women younger than 50 years o age, with-high grade neoplasia, Ki-6 o or above, or
who had undergone a quadrantectomy.
Fig. 39-2
STUDY 2: CUMULATIVE INCIDENCE OF LOCAL EVENTS: 5 YEARS
0.5
0.4
0.3
0.2
0.1
0
0
1
2
3
4
5
Years from baseline
No lipofilling
Lipofilling
p value: 0.02
HRfat grafting vs no fat grafting = 4.5 (95% confidence interval 1.1-18.2)
5-year cumulative incidence:
Fat grafting: 18%
No fat grafting: 3%
C
u
m
u
l
a
t
i
v
e

i
n
c
i
d
e
n
c
e
At risk
Fat grafting
50
57
40
30
18
11
No fat grafting
118
117
107
78
44
16
Both Milan studies showed an increased risk o locoregional recurrence in the group with in situ cancer
who underwent at gra ing.13
C om p l i ca ti on s
RECIPIENT SITE COMPLICATIONS
Fat necrosis, oil cyst ormation, and calcif cations can occur as a result o injecting large volumes o at
into a single area or injecting at into poorly vascularized areas, resulting in ailure o gra take. T is
leads to palpable mass ormation resulting rom at necrosis, which may be di cult to distinguish clini-
cally rom a locoregional recurrence in breast cancer patients and require additional imaging and needle
biopsy ( % to 5%). Moreover, calcif cation that occurs a er at gra ing can be identif ed with mam-
mography (0. % to .9%). In ection occurs in 0.6% to . % o at gra ed patients, and undercorrection
or overcorrection o the de ormity is another concern. Exceptional complications include damage to
underlying structures such as breast implants, pneumothorax, and intravascular injection causing a at
embolism.

725
Chapter 39 • Oncologic Risks o Fat Gra ting o the Breast
DONOR SITE COMPLICATIONS
Complications at the donor site appear to be minimal and are related to the liposuction technique. Pos-
sible sequelae include bruising, swelling, hematoma ormation, paresthesia or donor site pain, in ection,
hypertrophic scarring, contour irregularities, and damage to an underlying structure rom intraperito-
neal or intramuscular penetration o the cannula.
D i scussi on
In a systematic review, Krastev et al14 analyzed articles on at gra ing. A er selection according to
the content o cancer data, the quality o the ollow-up, and the size o the series, the authors retrieved
only two retrospective studies with a control group. In , in a review study o eight articles, Chan et
al15 ound that most indications o at gra ing were not or breast cancer patients but or benign pur-
poses. No specif c oncologic ollow-up was mentioned. o prove the sa ety o at gra ing in breast cancer
patients, Rigotti et al16 used the time interval between a radical mastectomy and the f rst at gra ing ses-
sion (period I) as the control or the time ollowing the f rst gra ing session (period II). However, since
the majority o recurrences develop in the f rst years a er cancer treatment, the rate o locoregional
recurrence in this group’s f rst period o ollow-up cannot be compared with the rate occurring a er a
longer ollow-up o patients a er at gra ing. Moreover, Rigotti et al did not include their series o
patients treated with conservative surgery or breast cancer. T e risk o cancer stimulation by at gra ing
may well be higher in patients undergoing conservative treatment than in those undergoing mastectomy.
In our Milan series we observed a trend o locoregional recurrence risk that was higher in the group who
received conservative treatment (p = . ).
Brenelli et al8 published a study o patients who underwent conservative breast treatment ollowed by
at gra ing. A er a mean ollow-up o years, they observed a locoregional recurrence rate o % per
year. Another series o at gra ing procedures by Delay et al3 demonstrated a low complication rate
and positive results. T ey concluded that the locoregional recurrence risk was not increased by the at
gra ing. T ey also suggested that preoperative and postoperative examination by a radiologist specializ-
ing in breast imaging is necessary to limit the risk that a cancer may occur coincidental with at gra ing.
Gale et al17 at Nottingham Breast Institute published a control study on patients with previously
treated malignant breast disease who underwent at gra ing, matched to the double o patients treated
or breast cancer without at gra ing. A er a mean ollow-up o months a er breast cancer and
months a er at gra ing, no signif cant excess oncologic events were observed with regard to local
( . % versus . %; p = . ), regional ( . % versus %; p = . ), and distant metastasis ( . % ver-
sus . %; p = . ). T e results o the DCIS did not show any increase o the locoregional recurrence.
But the number o in situ cases in the Gale study was only patients. Moreover, a recent review o our
results in Milan,9,10 analyzed a er a longer ollow-up, did not show any more signif cant di erence be-
tween the two groups o patients with or without at gra ing. In a recent unpublished study per ormed
at the IEO in Milan on breast conservative treatments ollowed by a at gra ing, we did not observe
an excess risk o locoregional recurrence in the study group compared with the control group.
Recently Kronowitz et al18 at M.D. Anderson published a large study o at gra ing per ormed a er
breast cancer treatment. T ey compared patients in the study group to controls. A er a mean
ollow-up o months a er mastectomy, months or controls, locoregional recurrence was observed
in . % o cases ( o breasts) and . % in the control group ( o breasts). T e cumulative
-year locoregional recurrence rates were . % and . % or cases and controls. Systemic recurrence
occurred in . % o cases and . % o controls (p = . ). T e investigators concluded that at gra ing
in breast cancer patients does not increase the risk o locoregional or systemic recurrences.

726
Part III • Clinical Applications • Breast: Reconstructive
Table 39-1 Summary of Study Results
Petit et al control studies9,10
No additional statistical increase in locoregional recurrence rate
in in situ cancer a er at gra ing (a er revision o the ollow-up)
Gale et al control study17
No increase o locoregional recurrence rate a er at gra ing
Kronowitz control study18
No increase o locoregional recurrence rate a er at gra ing
Milan control study (unpublished results) No increase o locoregional recurrence rate a er at gra ing
T ese studies provide signif cant support regarding the sa ety o at gra ing in breast cancer patients.
However, we do not have similar conf rmation regarding at gra ing with the enrichment technique
currently being investigated. T e technique involves processing the lipoaspirate to concentrate the pro-
genitor cells in the specimen o at, which is then injected in the de ect. T is technique has demonstrated
the possibility o improving the quality o healing with the at gra and increased preservation o viable
atty tissue a er gra ing.19 Clinical studies with match controls will be essential to demonstrate that the
highest concentration o progenitor cells does not stimulate the “dormant” cancer cells and increase the
risk o locoregional recurrences.
o prove the sa ety o at gra ing in breast cancer patients, a randomized trial would have been required.
Such randomization could only be proposed i there is an alternative procedure to the at gra ing such
as the injection o tissue f llers. However, the surgical complication o these f llers seems too high to pro-
pose such randomized study and there is no oncological sa ety in these products available.19 Moreover,
a randomization between at gra ing or no at gra ing cannot be proposed to the woman who requires
a cosmetic improvement.
Recently, a number o new techniques have been described, primarily based on enzymatic procedures,
to increase the percentage o preadipocytes in the specimen, allowing a possible better gra take. A
randomized study by Kølle et al20 showed clear improvement o the take o the at gra when it was pro-
cessed with the enrichment technique. Un ortunately, no reliable clinical cancer study was per ormed
to evaluate the locoregional recurrence risk a er the enrichment technique was employed. A “restore
study” mentioned the absence o locoregional recurrence a er a very short ollow-up and without any
comparison with a control group.21 Such cancer analysis is urgently required or these enrichment tech-
niques, because the risk o stimulation o the cancer cells results in the paracrine e ect o the proteins
secreted by the progenitor cells o the adipocytes. Increasing the percentage o stem cells in the specimen
injected could increase the risk o stimulation o the cancer cells. Willemsen et al22 have investigated
another approach to stimulate the paracrine unction o the progenitor cells: platelet-rich plasma (PRP)
(see Chapter ). T e process appears to have an in uence on both the expansion and paracrine unc-
tion o adipose-derived stromal cells in a dose-dependent ashion. All enrichment techniques should be
evaluated clinically to conf rm their oncologic sa ety.
T ere is increasing evidence that obesity is associated with the increased requency and morbidity o
several types o neoplastic diseases, including postmenopausal breast cancer. Disruption o the energy
homeostasis results in obesity, in ammation, and alterations o adipokine signaling that may oster ini-
tiation and progression o cancer. Preclinical studies have suggested that di erentiated cells o the white
adipose tissue (WA ) and WA -resident progenitors may also promote cancer growth and metasta-
sis.11,23,24 We reported that CD 5− CD + progenitors rom human WA may promote breast cancer
growth and metastases in preclinical models. Other recent studies, some o which are based on endog-
enous WA expressing a transgenic reporter, showed a signif cant level o adipose cell contribution to
tumor composition. However, WA contains several distinct populations o progenitors, and the data
in these studies were obtained using crude or mixed cell populations. We there ore decided to puri y by
sorting the two quantitatively most relevant populations o WA progenitors (endothelial progenitor
cells [EPCs] and adipose-derived stromal cells [ADSCs]) and to investigate, in vitro and in vivo, their
role in several orthotopic models o local and metastatic breast cancer. One study recently ound that
EPCs are present in tissues other than the bone marrow, in particular in the adipose tissue o mice. We

727
Chapter 39 • Oncologic Risks o Fat Gra ting o the Breast
reported that human WA is a very rich reservoir o CD45− CD 4+ EPCs. When compared with bone
marrow–derived CD 4+ cells mobilized in blood by granulocyte colony–stimulating actor (G-CSF),
purif ed human WA -derived CD 4+ cells were ound to express similar levels o stemness-related
genes and signif cantly increased levels o angiogenesis-related genes and o FAP-alpha, a crucial sup-
pressor o antitumor immunity. In vitro, WA -CD 4+ cells generated mature endothelial cells and en-
dothelial tubes. In vivo, the coinjection o human WA -CD 4+ cells contributed to tumor vasculariza-
tion orthotopic and signif cantly increased tumor growth and metastases in models o human breast
cancer in nonobese diabetic severe combined immunodef cient (NOD/SCID) interleukin- receptor
gamma (IL- R-gamma)–null (NSG) mice.
C oncl usi on
We have now reached the crucial point o the limits o translational research. Many investigators are
working on the complex properties o atty tissue and expanding its applications, whereas clinicians
(plastic surgeons) are f nding that the results o experimental research to date on animals cannot be ap-
plied to their emale patients. T ey stress that the conditions and results o experiments on mice are to-
tally di erent rom those associated with at gra ing in a clinical setting. T e last word has not been said
on this promising line o research, and urther clinical studies are essential to better conf rm the sa ety o
at gra ing in breast cancer patients, especially regarding the potential o enrichment techniques.
REFERENCES
1. Coleman SR, Saboeiro AP. Fat gra ing to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
11 : 5, 00 .
. Spear SL, Wilson HB, Lockwood MD. Fat injection to correct contour de ormities in the reconstructed
breast. Plast Reconstr Surg 116:1 00, 005.
. Delay E, Garson S, ousson G, et al. Fat injection to the breast: technique, results, and indications based
on 880 procedures over 10 years. Aesthet Surg J : 60, 00 .
4. Gutowski KA, Baker SB, Coleman SR, et al. Current applications and sa ety o autologous at gra s: a
report o the ASPS Fat Gra ask Force. Plast Reconstr Surg 1 4: , 00 .
5. Delay E, Gosset J, oussoun G, et al. [E cacy o lipomodelling or the management o sequelae o breast
cancer conservative treatment] Ann Chir Plast Esthet 5 :15 , 008.
6. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment o radiotherapy tissue damage by lipoaspirate
transplant: a healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg 11 :140 ,
00 .
. Pulagam SR, Poulton , Mamounas EP. Long-term clinical and radiologic results with autologous at
transplantation or breast augmentation: case reports and review o the literature. Breast J 1 :6 , 006.
8. Brenelli F, Rietjens M, De Lorenzi F, et al. Oncological sa ety o autologous at gra ing a er breast conser-
vative treatment: a prospective evaluation. Breast J 0:15 , 014.
. Petit JY, Botteri E, Lohsiriwat V, et al. Locoregional recurrence risk a er lipof lling in breast cancer pa-
tients. Ann Oncol :58 , 01 .
10. Petit JY, Rietjens M, Botteri E, et al. Evaluation o at gra ing sa ety in patients with intraepithelial neopla-
sia: a matched-cohort study. Ann Oncol 4:14 , 01 .
11. Vona-Davis L, Rose DP. Adipokines as endocrine, paracrine, and autocrine actors in breast cancer risk
and progression. Endocr Relat Cancer 14:18 , 00 .
1 . Société Francaise de Chirurgie Plastique Reconstructrice et Esthétique. Available at
ticiens.org/.
1 . Botteri E, Bagnardi V, Rotmensz N, et al. Analysis o local and regional recurrences in breast cancer a er
conservative surgery. Ann Oncol 1: , 010.

728
Part III • Clinical Applications • Breast: Reconstructive
14. Krastev K, Jonasse Y, Kon M. Oncological sa ety o autologous lipoaspirate gra ing in breast cancer
patients: a systematic review. Ann Surg 0:111, 013.
15. Chan CW, McCulley SJ, Macmillan RD. Autologous at trans er—a review o the literature with a ocus on
breast cancer surgery. J Plast Reconstr Aesthet Surg 61:143 , 00 .
16. Rigotti G, Marchi A, Stringhini P, et al. Determining the oncological risk o autologous lipoaspirate gra -
ing or post-mastectomy breast reconstruction. Aesthetic Plast Surg 34:4 5, 010.
1 . Gale KL, Rakha EA, Ball G, et al. A case-controlled study o the oncologic sa ety o at gra ing. Plast Re-
constr Surg 135:1 63, 015.
1 . Kronowitz SJ, Mandujano CC, Liu J, et al. Lipof lling o the breast does not increase the risk o recurrence
o breast cancer: a matched controlled study. Plast Reconstr Surg 13 :3 5, 016
19. McCleave MJ, Grover R, Jones BM. Breast enhancement using Macrolane: a report o complications in
three patients and a review o this new product. J Plast Reconstr Aesthet Surg 63: 10 , 010.
0. Kølle SF, Fischer-Nielsen A, Mathiasen AB, et al. Enrichment o autologous at gra s with ex-vivo ex-
panded adipose tissue-derived stem cells or gra survival: a randomised placebo-controlled trial. Lancet
3 (9 9 ):1113, 013.
1. Pérez-Cano R, Vranckx JJ, Lasso JM, et al. Prospective trial o adipose-derived regenerative cell
(ADRC)-enriched at gra ing or partial mastectomy de ects: the RES ORE- trial. Eur J Surg Oncol
3 :3 , 01 .
. Willemsen JC, Spiekman M, Stevens HP, et al. Platelet-rich plasma in uences expansion and paracrine
unction o adipose-derived stromal cells in a dose-dependent ashion. Plast Reconstr Surg 13 :554e,
016.
3. Bertolini F, Petit JY, Kolonin MG. Stem cells rom adipose tissue and breast cancer: hype, risks and hope.
Br J Cancer 11 :419, 015.
4. Martin-Padura I, Gregato G, Marighetti P, et al. T e white adipose tissue used in lipotrans er procedures
is a rich reservoir o CD34+ progenitors able to promote cancer. Cancer Res :3 5, 01 .

729
C h a p t e r 4 0
I w c c h w h xc ,
ch h h h , h h c h v . T
h h c h c c ,
h w k I z1 F .2 H w v , h h h
, c h ch q w c h h
c . A h , c w ch , c
w f v . A f w f h ch q
w v h c v w h w k B c .3,4 T c
c h A c S c P c R c c v S
h h 5: “T c h
j c ; ch h j c w v v ,
h k w h c c h c c c f c . A
, c c c h h x h h w -
c c , h c c v .” T c h ASPRS
q ch x h f .
I w w w h w k C ,6,7 wh h c
c c c w w .
B c h v v c c j v h c c
c , w v ch c v h c c -
h h c . T w k w v w ch q , wh ch
w c lipomodeling,8,9 c f h v c h 4,10
c f h h w c c c c .11-13
Lipomodel ing or Congenit al
Br east De or mit ies:
uber ous Br east s, Pol and
Syndr ome, and Asymmet r y
Emmanuel Delay, Samia Guerid

730
Part III • Clinical Applications • Breast: Reconstructive
When we f rst presented our work at the Société Française de Chirurgie Plastique et Reconstructrice
and at international society meetings, our reports were the subject o criticism, with the same arguments
used as in the s controversy. We then designed scientif c studies to address every argument point-
by-point with scientif c evidence. As we presented our work, hostility in the community began to de-
crease, and over time at gra ing to the breast became a well described and accepted procedure or breast
reconstruction.4,8,9,14 We then progressively expanded our indications to the thoracomammary region.
In this chapter we present the relevance o at gra ing or the treatment o asymmetries and congenital
breast de ormities and discuss the expected results o the lipomodeling technique.
M
a teri a l a n d M
eth od s
SURGICAL TECHNIQUE
Fig. 40-1, A-F
Marking recipient and harvest sites
A
B
C
Centrifugation
Infiltration of tumescent fluid

Harvesting
D
E
F

731
Chapter 40 • Lipomodeling or Congenital Breast De ormities
Fig. 40-1, G-L
Purification of lipoaspirate and transfer to syringes
G
H

I
Fat grafting

Fasciotomies

Thumb-blocking technique
J

K
L
We have used breast lipomodeling since in our department. We progressively developed an accu-
rate technique allowing maximum e ciency o a large-volume at trans er to the breast (megavolume
trans er). Recent works also contributed to the standardization o the harvesting and trans er techniques,
thus minimizing the hazards o each step. Precision in per orming each step is the key to at survival in
the short, medium, and long term.4,6,8,9
Be ore any lipomodeling procedure can be planned, the patient must be at her ideal weight, because
trans erred at maintains a “memory” o its origin, and i the patient loses weight a er lipomodeling, she
will lose part o the benef t o its e ects. Breast ultrasonography is always per ormed by a well-trained
breast radiologist be ore surgery as a baseline, and another ultrasound is obtained year a er the last
session o lipomodeling to be used as a re erence. I the patient is more than years old, mammography
is added to this protocol.12,13 T e patient is thoroughly instructed be ore surgery about the procedure,
the ollow-up, and the need or preoperative and postoperative radiologic surveillance so that any newly
arising or preexisting breast cancer will not be overlooked.15
T e surgeon must f rst evaluate the areas to be treated in the breast and thorax. T ese areas are marked
with the patient standing. T en potential at harvesting zones are evaluated to highlight natural at de-
posits. Abdominal at is generally the f rst choice o a donor site, because it does not require any position
change during surgery. However, in teenagers or young adults, the at volume o the abdomen can be
limited. Second choices are the saddlebags and medial aspects o the thighs and knees. Outlines o har-
vesting zones are drawn with a surgical marker.

732
Part III • Clinical Applications • Breast: Reconstructive
Because a signif cant amount o at is typically needed or the procedure, general anesthesia is used or
most patients. A classical prophylactic antibiotic is usually given preoperatively i another surgery is
planned at the same time, as is usual in plastic surgery. Lipomodeling itsel requires no specif c antibi-
otic. Local anesthesia only is used or small corrections o potential residual imper ections.
In the at donor sites, small incisions are made with a No. 15 blade. I abdominal harvesting is done, we
use our periumbilical incisions. One lateral incision is added on each side i lateroabdominal areas and
at above the iliac bone are to be harvested. On the thighs, we use an incision in the buttock crease on
each side, and o en an incision on the medial aspect o the knees.
In the recipient sites, we try to conceal incisions in previous scars. o cross the numerous trans er tun-
nels, one has to make three or our incisions, with two o them located in the in ramammary old. Inci-
sions are made by means o the cutting edge o an 18-gauge needle to limit their length.
We use harvesting cannulas with blunt tips and f ve holes, with a diameter o .5 mm. Harvesting is done
with a 10 cc Luer-Lok syringe attached to the cannula. Aspiration is per ormed with a minimal vacuum
pressure and delicate handling so that adipose cells are not injured; violent mechanical aspiration can
have a deleterious e ect on cell survival. T e total amount o lipoaspirate has to compensate or the loss
o the waste ractions separated by centri ugation, as well as the necessary overcorrection during at
gra ing. Incisions are closed with thin rapid-absorbable suture.
During harvesting, an operative assistant will prepare syringes or centri ugation: screw caps are placed
on the syringes, which are then centri uged at 000 rpm or 0 seconds. T e team must be well organized
to handle at properly and quickly. By means o the three-way valve, purif ed at is trans erred rom the
centri uged syringes to 10 cc syringes.
At the completion o at processing there will be numerous 10 cc syringes o purif ed at. Fat gra ing
can then be done in the thoracomammary region with the 10 cc syringes on which a trans er cannula
mm in diameter is attached. T ese cannulas are slightly longer and stronger than the ones used or at
gra ing to the ace, because the mechanical demands o gra ing in the breast are di erent. Breast inci-
sions are made with an 18-gauge needle, which allows adequate access yet limits scar length, which will
be a mere dot, hardly noticeable. More than one incision is made to allow multiple crisscrossing gra ing
tunnels.
T e surgeon must have thorough knowledge o the anatomy o the thoracomammary region. Gra s are
placed rom the bony plane o the ribs to the cutaneous level, and it is very important to be aware o each
tissue layer’s thickness. For correction o a congenital de ormity, it is essential to evaluate individual vari-
ations in each layer on the sur ace o the projecting breast mound. A capacity or mentally visualizing
these di erent layers in a three-dimensional grid is a valuable asset or the surgeon and relies on his or
her surgical experience in breast surgery. T e anatomy o the in raclavicular vessels and brachial plexus
must also be well understood. Great care must be exercised while trans erring at to the upper thoracic
region to prevent injury o the in raclavicular vessels or creating brachial plexus lesions. T e depth o
cannula insertion must be kept under strict control throughout multiple thrusts into the tissue.

733
Chapter 40 • Lipomodeling or Congenital Breast De ormities
Gra ing is done in very small quantities in the orm o ultrathin, spaghetti-like cylinders o at in mul-
tidirectional microtunnels, working rom the deep to the superf cial plane. T e fat is transferred as the
cannula is withdrawn, not as it enters the microtunnel. A large lobule o at must not be gra ed or an ex-
cessive amount injected in the same level and zone, which would lead to at necrosis. Each microtunnel
should be placed so that it is enveloped by well-vascularized tissue.
T e asciotomy maneuver is a very important technique to consider when treating patients with a breast
de ormity. It is particularly use ul or treating scar retraction and a lack o skin expansion. T e technique
consists o sectioning f brous tracts that would prevent skin expansion. Fasciotomies must be done in
several di erent levels to allow global tissue expansion without devascularization, which would predis-
pose the tissue to at necrosis. T e technique consists o putting f brous tracts under tension by pulling
the skin with a double hook and cutting the f brous tracts with the tip o an 8-gauge needle.16
Lipomodeling requires overcorrection i the recipient tissues allow it, because a % volume resorption
o at (2 % to %, depending on at quality) can be expected. When the recipient site is saturated with
at and can accept no urther lipoaspirate, gra ing must be discontinued to avoid creating at necrosis
zones; this may be re erred to as the principle o respecting recipient site saturation. Breast injection sites
are closed with a thin ast-absorbing suture, and a simple dry dressing is applied or a ew days.
T e pain patients experience at the harvest sites will be the same as or any liposuction procedure. Pa-
tients complain o a sharp pain or the f rst 8 hours, which can be treated with simple analgesics. We
inf ltrate the region with dilute ropivacaine at the end o the harvesting procedure, which reduces the
discom ort at the harvest sites during the f rst 2 hours. T e patient will have an unpleasant sensation
at these sites or 2 to months. Bruising is signif cant and lasts or about weeks. Postoperative edema
resolves completely or almost completely within months.
On the breasts, bruises last or approximately 5 days. Postoperative edema in the breasts resolves in
about month. issue volume will shi toward a progressive loss o about % o trans erred at, but the
patient may have the impression that a 5 % loss is taking place, because she saw the result the day a er
surgery when edematous volume was at its highest. T is must all be discussed with the patient preoper-
atively, with assurances that her breast volume will stabilize a er to months.
R esul ts
T e lipomodeling technique was initially described or breast reconstruction with an autologous latissi-
mus dorsi ap. Since January 2 , we have used lipomodeling systematically in our department or the
treatment o asymmetries and thoracomammary congenital de ormities. T e senior author per ormed
28 procedures rom January 2 to September 2 or reconstruction without implants in cases o
slight asymmetry, cases o signif cant asymmetry with unilateral hypotrophy, cases o asymmetry
rom pectus excavatum, 9 cases o tuberous breasts, and cases o Poland syndrome.

734
Part III • Clinical Applications • Breast: Reconstructive
SLIGHT ASYMMETRY
Slight asymmetry is one o the best indications or lipomodeling. T e technique allows not only moder-
ate augmentation o the smaller breast without the need or an implant but also correction o the contour
o the def cient breast, resulting in almost per ect symmetry.
Fig. 40-2
T is patient with moderate breast asymmetry was treated with one lipomodeling session o the le
breast in which 20 cc was injected. T e result is shown 12 months postoperatively. In most cases o
slight asymmetry, one session is usually su cient; the mean trans er amount is 220 cc. Our patients’
results have been satis actory with this procedure.

735
Chapter 40 • Lipomodeling or Congenital Breast De ormities
SIGNIFICANT ASYMMETRY WITH UNILATERAL HYPOPLASIA
For a signif cant asymmetry, two sessions are planned to ensure obtaining ideal symmetry. We usually
wait months between the two sessions, but this period o time can be longer with no e ect on the f nal
result. In a patient with a ptotic or hypertrophic contralateral breast, a contralateral reduction or mas-
topexy can be per ormed during the second session. With at gra ing a unilateral implant is not required
on the hypotrophic side, which would inevitably lead to recurrence o an asymmetry in the uture as a
result o the di erent evolution o the breasts. With lipomodeling, symmetry is stable over time i the
patient’s weight remains stable.
Fig. 40-3
T is 2 -year-old woman presented with signif cant asymmetry o her breasts. reatment required two
lipomodeling sessions o the le breast. In the f rst session 1 9 cc was injected, and in the second session
2 6 cc was trans erred. Her results are shown 12 months a er the second procedure.

736
Part III • Clinical Applications • Breast: Reconstructive
ASYMMETRY WITH PECTUS EXCAVATUM
Pectus excavatum is a complex congenital de ormity o the sternum and rib breastplate corresponding to
an anteroposterior sinking. T e actual unctional impact is usually very low or absent; the de ormity is
o an essentially morphologic or aesthetic concern, with greater mammary impact i the pectus is severe
or unilateral.
Fig. 40-4
T is 20-year-old woman presented with asymmetry and unilateral pectus excavatum. She was treated
with two lipomodeling sessions in which 2 cc and 288 cc were trans erred, respectively. Her result is
shown 2 months a er the second session.
T e breast asymmetry o pectus excavatum can be exacerbated by implants. Current treatments are ster-
nochondroplasties and placement o a custom-made silicone implant. However, lipomodeling seems
to us to be o greater value than those technically heavy solutions, and it does produce a custom re-
sult.17 For correction o asymmetry, the surgeon requires experience to be able to evaluate the amount
o at to be trans erred, because correction o the de ormity requires a signif cant amount o gra ed at.
T e technique allows correction o pseudo-breast asymmetry associated with a thoracic de ormation,
as in the case o unilateral pectus excavatum. wo lipomodeling sessions are usually needed to obtain
a proper correction o the asymmetry. In severe pectus excavatum in a very thin patient who does not
have enough available at to correct the de ormity, lipomodeling can be used as an adjunct to the place-
ment o a sti silicone implant, which is custom-made based on a D C scan.

737
Chapter 40 • Lipomodeling or Congenital Breast De ormities
TUBEROUS BREASTS
A tuberous breast is a congenital de ormity o the mammary ootprint that f rst becomes noticeable
during puberty, when breast volume increases. Various surgical procedures have been described, and
there is a broad choice o techniques to obtain the best possible results. A number o lipomodeling
applications can be employed to correct the lack o volume (especially i the de ormity is unilateral)
while improving the breast base and shape.18 Fasciotomies can lower the in ramammary old and create
a pleasant lower breast pole while releasing the f brous ring.16 For signif cant ptosis or areolar hernia-
tion, a mammaplasty may be adequate. Lipomodeling can be used as a complementary technique in the
décolleté region and to create a breast base that matches the contralateral side. T e best indications are
a hypotrophic unilateral tuberous breast (which generally requires sessions o at trans er) and lack o
upper breast pole ullness.
Fig. 40-5
T is -year-old patient with tuberous breasts was treated with two separate lipomodeling sessions in
which cc and cc were gra ed to the right breast. We also per ormed a reduction mammaplasty
o the le breast in which 2 g was removed. She is seen months a er the second procedure.
For treatment o tuberous breasts with bilateral hypotrophy, breast implants are the mainstay, because
the at requirements would be too high or e ective bilateral augmentation. Among the 5 tuberous
breasts cases treated by the senior author over 5 years, lipomodeling was used exclusively, without an
implant, in 92 cases.

738
Part III • Clinical Applications • Breast: Reconstructive
POLAND SYNDROME
Correction o the thoracic and breast congenital de ormity o Poland syndrome is a challenge or the
plastic surgeon. For this anomalous condition, lipomodeling is an important tool that can produce an
excellent quality breast reconstruction with simple repeated procedures with a very limited scar bur-
den.19,20 T e surgeon must be mind ul o the position o the subclavian vessels, which can requently be
situated lower than usual in these patients. It is o outmost importance to palpate the exact position o
the cannula tip with the other hand be ore at gra ing to prevent intravascular injection or a lesion o
those structures, which could produce serious consequences.
T e results are remarkable; a breast almost identical to the contralateral breast can be achieved. T is
technique has introduced a true revolution in the treatment o patients with Poland syndrome. De-
pending on the severity o the de ormity, two to f ve sessions are needed to obtain the desired outcome,
usually with months between sessions. Integration o body image usually occurs with little di culty,
because this technique produces a progressive growth o the breast, mimicking normal breast growth.
Similarly, sensation is excellent, especially i the patient is taught to practice rehabilitation o sensation
a er each session by touching her breast in ront o a mirror to appropriate it.
Fig. 40-6
T is 4-year-old patient with Poland syndrome de ormity was treated with three lipomodeling sessions
in which 6 cc, 5 cc, 5 cc o at was gra ed. A vertical mastopexy and a 5 g breast reduction were
per ormed during the third session. Her results are seen months later.

739
Chapter 40 • Lipomodeling or Congenital Breast De ormities
C ompl i ca ti on s
O 2 lipomodeling surgeries per ormed by the senior author rom 1 8 to September 2 1 , there
were 12 in ections and 1 pneumothorax. We had only 1 case o in ection in a patient with pectus excava-
tum. T is appeared as an erythema o the treated area region; the patient reported pain and exhaustion.
T e area was drained with the use o a local anesthetic, antibiotics were prescribed, and the in amma-
tion resolved. T is complication had no impact on her f nal aesthetic result, which was excellent. We
also had 2 cases o breast hypertrophy in patients whose hypotrophic breasts had been corrected with
lipomodeling; in both cases the problem was created when the patients gained weight. A er their weight
stabilized, the patients were treated with unilateral reduction mammaplasties.
D i scussi on
Contraindications to lipomodeling are ew. T e procedure may not be able to achieve the desired aes-
thetic goals in an extremely thin patient with very little at available or liposuction. Patients must have
more than enough adipose tissue to complete the correction, because o the rule o %: there will be a
loss o about % o harvested at during centri ugation and preparation, and a er at gra ing, a loss o
about % o trans erred volume can be expected as a result o the resorption that occurs over the f rst
months a er a lipomodeling procedure. In selected cases, the contraindication may be relative i it is
possible to harvest at rom multiple zones, but the harvesting procedure will be more complex and will
take more time.
Lipomodeling o a thoracomammary congenital de ormity is a well-established technique. It can provide
excellent results with very little scarring. However, to prevent the occurrence o aesthetic complications
that can impair results quality, certain essential rules have to be ollowed. o prevent at necrosis that can
lead sometimes to concerns about breast tumor, two principles have to be respected:

1. T e 3D network principle: At the end o surgery, the breast has to be like a 3D mesh o adipose
tissue “spaghetti.” Gra ing routes have to be layered and crisscrossed to avoid creating a reservoir
o at.

2. T e recipient site saturation principle: When the recipient tissue is saturated with at, when con-
tinued injections o at through an incision result in at owing out through another incision, at
gra ing must be discontinued.
o obtain proper areolar projection while limiting the risk o pneumothorax, the surgeon has to work
rom two in ramammary old incisions made at the median point o the old. From these two incisions,
at has to be trans erred under the areolar zone (or the uture areolar zone) in a cone-shaped maneuver.
It is benef cial to visualize the injected at as f lling the microtunnels to orm the “tent poles” o a teepee.
It is then possible to improve areolar projection without working rom the areolar zone. Fat trans er
rom the areolar zone itsel would orce the surgeon to work in a perpendicular ashion to the ribs, car-
rying the potential risk o pneumothorax.
o control the uture in ramammary old location when it is situated too high (as may occur mainly in
Poland syndrome or a type 2 tuberous breast), the IMF can be lowered by means o lipomodeling in a
specif c maneuver called the thumb-blocking technique. Once the desired in ramammary old level has
been def ned and marked, the surgeon uses the f rst web o the le hand to lock the right in ramammary
old level. While widely opening the f rst web o the le hand and placing it at desired level, the surgeon
realizes the lipomodeling rom the areolar zone, hitting le hand blocked skin. In this way the in ra-
mammary old can be lowered by 2 to cm or even more. T is maneuver is valuable to prevent the risk
o lowering the old too much and to allow or a sa e and accurate surgical procedure.
Lipomodeling is the ideal technique or treating breast asymmetries and congenital breast de ormities
and should be o ered as a f rst-line treatment or these indications. It can almost always be per ormed

740
Part III • Clinical Applications • Breast: Reconstructive
without the need or a silicone implant. Only in thin patients with very little available at or in secondary
cases with previous implant placement are we using combined techniques with an implant plus lipo-
modeling.
C oncl u si on
Fat gra ing is a signif cant advance in the treatment o breast asymmetries and congenital de ormities.
Breast asymmetry is an ideal indication or lipomodeling. It is no longer necessary to treat an asymmetry
with an implant in most cases. T e symmetry achieved is both e cacious and long-lasting i the patient’s
weight remains stable. T e application o lipomodeling to other thoracomammary congenital de ormi-
ties is a growing f eld. In Poland syndrome, at gra ing has been used with excellent results; it is likely
that this technique will completely change the treatment o severe cases while allowing reconstructions
o unprecedented quality. Fewer procedures are required, ollow-up is straight orward, and scarring is
minimal. Lipomodeling is also indicated to correct thoracomammary de ormities such as unilateral or
bilateral pectus excavatum and is a therapeutic alternative or treatment o tuberous breasts without the
need or an implant, especially when hypotrophy is unilateral.
REFERENCES
1. Illouz YG. La Sculpture Chirurgicale par Lipoplastie. Paris: Arnette, 1988.
2. Fournier PF. Liposculture: T e Syringe echnique. Paris: Arnette Blackwell, 1991.
3. Bircoll M. Cosmetic breast augmentation utilizing autologous at and liposuction techniques. Plast Re-
constr Surg 9:26 , 198 .
. Delay E. Breast de ormities. In Coleman SR, Mazzola RF, eds. Fat injection: From Filling to Regeneration.
St Louis: Quality Medical Publishing, 2 9.
5. ASPRS Ad-Hoc Committee on New Procedures. Report on autologous at transplantation, September 3 ,
198 . Plast Surg Nurs :1 , 198 .
6. Coleman SR. Long-term survival o at transplants: controlled demonstrations. Aesthetic Plast Surg 19:
21, 1995.
. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 2 :3 , 199 .
8. Delay E, Delaporte , Sinna R. [Breast implant alternatives] Ann Chir Plast Esthét 5 :652, 2 5.
9. Delay E. Lipomodeling o the reconstructed breast. In SE Spear, ed. Surgery o the Breast: Principles and
Art, ed 3. Philadelphia: Lippincott Williams & Wilkins, 2 11.
1 . Sinna R, Delay E, Garson S, Mojallal A. [Scientif c bases o at trans er. Critical review o the literature]
Ann Chir Plast Esthét 51:223, 2 6.
11. Pierre eu-Lagrange AC, Delay E, Guerin N, et al. [Radiological evaluation o breasts reconstructed with
lipomodeling] Ann Chir Plast Esthét 51:18, 2 6.
12. Carloni R, Delay E, Gourari A, et al. Preoperative imaging prior to breast reconstruction surgery: bench-
marking bringing together radiologists and plastic surgeons. Proposed guidelines. Ann Chir Plast Esthét
59:e13, 2 1 .
13. Veber M, ourasse C, oussoun G, Moutran M, Mojallal A, Delay E. Radiological f ndings a er breast
augmentation by autologous at trans er. Plast Reconstr Surg 12 :1289, 2 11.
1 . Coleman SR, Saboeiro AP. Fat gra ing to the breast revisited: sa ety and e cacy. Plast Reconstr Surg
119: 5, 2 .

741
Chapter 40 • Lipomodeling or Congenital Breast De ormities
5. Delay E, Sinna R, Delaporte T, et al. Patient in ormation be ore aesthetic lipomodeling (lipoaugmenta-
tion): a French plastic surgeon’s perspective. Aesthet Surg J 29:386, 2 9.
6. Ho Quoc C, Sinna R, Gourari A, La Marca S, Toussoun G, Delay E. Percutaneous asciotomies and at
gra ing: indications or breast surgery. Aesthet Surg J 33:995, 2 3.
. Ho Quoc C, Delaporte T, Meruta A, La Marca S, Toussoun G, Delay E. Breast asymmetry and pectus ex-
cavatum improvement with at gra ing. Aesthet Surg J 33:822, 2 3.
8. Delay E, Sinna R, Ho Quoc C. Tuberous breast correction by at gra ing. Aesthet Surg J 33:522, 2 3.
9. Delay E, Sinna R, Chekaroua K, et al. Lipomodeling o Poland’s syndrome: a new treatment o the tho-
racic de ormity. Aesthet Plast Surg 3 :2 8, 2 .
2 . Coudurier J, Ho Quoc C, Ismail M, Dlimi C, Tourasse C, Delay E. [Long-term outcome o lipomodeling
in Poland’s syndrome: about our f rst case with an eleven-years’ ollow-up] Ann Chir Plast Esthét 6 :65,
2 5.

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PREOPERATIVE EXAMINATION
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743
Reconst r uct ion o Br east
De or mit ies
Alessandra Marchi, Alberto Marchetti, Gino Rigotti

744
Part III • Clinical Applications • Breast: Reconstructive
Complete assessment begins with a care ul physical examination. T e breasts’ shape, volume, skin, and
nipple-areola complex are evaluated. Bilateral di erences in contour and volume are documented, pho-
tographed, and discussed with the patient. T is will help the surgeon to estimate the amount o lipoaspi-
rate that must be harvested to produce adequate volume or at gra ing to the breast. T e thickness,
elasticity, color, and texture o the skin should be care ully evaluated, and the presence o stretch marks
should be noted. T e breast parenchyma is assessed or texture, shape, and distribution in all our quad-
rants.
T e presence o giant f broadenomas or cancer, which may be misdiagnosed in the presence o breast
asymmetry, should be assessed. Breast ultrasonography, mammography, and MRI are also essential to
clari y volume and atty or glandular breast structures and any indications o the presence o cancer.
Chest radiographs and C scans are use ul in patients with skeletal diseases or complex mal ormations.
Abdominal ultrasonography is use ul to exclude the kidney diseases that are requently related to severe
breast mal ormation.
Accurate photographs are essential to document the patient’s preoperative and postoperative appear-
ance. Photographs are taken with the patient standing with her arms loose at the sides in rontal, oblique,
and lateral views. T ese photographs help the surgeon to establish the reconstructive plan, document the
changes, and conf rm the results obtained a er surgery and at each ollow-up visit.
SURGICAL TECHNIQUE
Preoperative Planning
One month be ore each surgical session, the BRAVA System, an external expansion device (see Chapter
2), should be applied on the patient’s thoracic wall or at least hours a day, usually during the night.
T e suction e ect o the external expansion device serves to enlarge the breast’s at gra ing recipient site.
T is allows a larger amount o lipoaspirate to be injected at each session, resulting in the need or ewer
procedures.3-7
As the negative pressure expands the skin envelope, it also improves skin so ness and increases the
grade o ptosis in the treated breast. T us the need or contralateral breast reshaping, mastopexy, or
breast reduction can be avoided or reduced.
T e BRAVA System should again be used as soon as possible a er at gra ing, when the symptoms
o bruising, pain, or ecchymosis have resolved, because it stimulates the proli eration o the adipose-
derived stem cells (ADSCs), increasing the f nal volume o the breast.8
Harvest of Lipoaspirate
T e lipoaspirate is harvested while the patient is deeply sedated. An antibiotic solution is administered
minutes be ore the procedure begins. T e donor areas in younger patients are primarily the anks
and trochanteric regions. T e donor areas are inf ltrated with a Klein solution: 5 ml o saline solution
with 2 ml o lidocaine .5% and : , epinephrine.9,10
Fat is harvested with a multihole blunt cannula, mm in diameter, connected to a 5 cc Luer-Lok sy-
ringe. T e harvested at parcels have smaller dimensions, thus enhancing the lipoaspirate distribution
and take.

745
Chapter 41 • Reconstruction o Breast De ormities
When su cient at has been harvested, the cannula is removed rom the syringe and replaced with a
plug. T e syringes are placed in a bowl and le or decantation as long as necessary, usually not more
than 0 minutes.
Purif cation
T e lipoaspirate separates into three layers, the lower containing uids, the middle containing the viable
at, and the upper containing oil rom ruptured adipose cells. T e oil and uids are discarded, and the
remaining purif ed lipoaspirate is trans erred to cc syringes or gra ing.6
Fat Distribution
wo main issues should be considered when per orming at distribution: the total amount o at to be
gra ed and the homogeneity o the deposition.
T e amount o at gra ed is patient specif c. T e at is distributed in di erent planes—subpectoralis,
subglandular, and subcutaneous—but should never be injected directly into the mammary gland. It is
important to avoid applying too much pressure when injecting, while drawing back the cannula to min-
imize any risk o arterial or venous embolization. T e ribbon o at is placed as the syringe is withdrawn,
not as it enters the tunnel. T e sti ness o the subcutaneous tissue and the skin retraction are crucial
actors and should be avoided to preserve some elasticity and so ness o the breast tissues.5,6
Homogeneity o the lipoaspirate distribution in the di erent layers maximizes its contact with the host-
ing tissue and increases the quality o the f nal results.5,11 Injection o bulky quantities o at results in at
necrosis, oil cysts, and macrocalcif cations.
Rigottomies
T e injection o adipose tissue in combination with percutaneous debridement with a -gauge needle
per ormed both in a bidimensional and tridimensional pattern rees adhesions and releases the con-
stricted gland.12,13
R esul ts
T e surgical approach to the correction o breast de ormities must ollow a precise sequential pattern. T e
surgical steps that we have developed over many years o clinical experience are as ollows:

. Fat gra ing into the submammary crease

. Rigottomies to lower the old

. Fat gra ing in multiple layers

. Filling and release o all quadrants with at gra and rigottomies

. Use o the BRAVA System
Each step must be executed in this order to allow or e ective breast f lling and shaping. T is protocol is
universal and can be applied to every patient, as demonstrated in the ollowing clinical cases. Obviously,
according to the needs o the specif c patient some surgical steps will require more e ort than others.

746
Part III • Clinical Applications • Breast: Reconstructive
MODERATE BREAST ASYMMETRY
Fig. 41-1, A-E
A
B
C
D
E
T is 20-year-old patient had moderate breast asymmetry and requested at graf ing to correct this but
did not want a mastopexy o the contralateral breast. T e right breast was hypotrophic, and the lef
breast was ptotic, with the nipple-areola complex pointing downward. T e skin was sof and elastic. Her
breast ootprints were symmetrical, with parallel in ramammary olds.

747
Chapter 41 • Reconstruction o Breast De ormities
F

G
H
Fig. 41-1, F-H
It was necessary to increase the volume and ptosis o the right breast. For the le breast, the plan was
to reduce the breast ptosis. T e patient wore the BRAVA device preoperatively and postoperatively only
on the right breast or 8 hours a day, and it was removed immediately be ore surgery. In the le breast
we injected a small amount o at, about 30 to 0 cc, along the entire in ramammary old. o reduce the
breast ptosis on the le , we had to reposition the old at a lower level to increase the distance between the
areolar edge and the in ramammary old.
Fig. 41-1, I and J
I

J
We per ormed rigottomies, a simple, noninvasive, and very ef ective approach. With a skin hook to keep
the skin under tension, a -gauge needle is used to detach the entire in ramammary old rom its orig-
inal position. Debridement is carried out until the old reaches the desired new position.
We injected some at along the entire old to prevent any retraction, thus stabilizing the result. T is pro-
duced a le breast that was less ptotic, with a more natural appearance.

748
Part III • Clinical Applications • Breast: Reconstructive
For the right breast, the operative plan was to increase both volume and ptosis o the breast. T e right
old was symmetrical with the contralateral old, so there was no need to reshape or reposition it.
o increase volume through at gra ing, the atty tissue should be injected in di erent planes o the
breast using a type II Coleman cannula. A very small amount o at should be placed with each pass, us-
ing many passes, starting rom the deepest layer, the in rapectoralis plane. It is sa er to start at gra ing at
the lateral quadrants, because it is easier to reach the correct plane. T e procedure should be per ormed
slowly and care ully to avoid damaging the underlying intercostal muscles or the pleura and to prevent
serious complications, such as hematomas or pneumothorax.
T e total amount o injected at should be 60 to 0 cc. T is procedure can improve the projection o the
breast.
T e retroglandular plane is injected next, again placing the parcels o atty tissue in many tunnels and
gra ing a very small amount o at with each pass. Di erent entrance points should be used to obtain a
more homogeneous distribution o the at. Injection o a bolus o at must be avoided; that would lead to
at resorption and to oil cyst ormation.
Next at is injected in the subcutaneous plane. T e lipoaspirate must be placed between the skin and the
gland, all over the entire breast. T is increases the so ness o the breast and improves the breast contour.
Fat should never be injected directly into the mammary gland.
Fig. 41-1, K
K
Fat gra ing was per ormed mainly at the level o the lower pole with blunt cannulas to increase breast
volume. T e pliability o the skin must be maintained to produce a natural eel and appearance to the
breast.
Fig. 41-1, L and M
L
M
Rigottomies were per ormed at the entire sur ace o the lower pole to release the breast skin and produce
ptosis to match the contralateral breast. T e result at the end o the f rst at gra ing session is shown.