Fat Injection From Filling to Regeneration

750
Part III • Clinical Applications • Breast: Reconstructive
Fig. 41-1, S-U
S
T

U
At the 41⁄2-year ollow-up visit, it was evident that the patient had gained a signif cant amount o weight.
Both breasts increased in size proportionally, maintaining and improving the symmetry. T e increase o
breast volume is associated with an increase in the degree o bilateral ptosis.

751
Chapter 41 • Reconstruction o Breast De ormities
SEVERE ASYMMETRY
Fig. 41-2, A-C
A
B

C
T is 2 -year-old woman had severe breast asymmetry. T e right breast was normally developed with
severe ptosis; the le breast was hypotrophic and ptotic.
T e patient underwent two at gra ing sessions in the le breast ( 30 cc and 300 cc) and reshaping o
the contralateral breast. T e surgical procedure was completed in 9 months. T e def nitive result has
improved with time, with progressive downward shi ing o the operated breast.

752
Part III • Clinical Applications • Breast: Reconstructive
Fig. 41-2, D-F
D
E

F
T e patient is seen years postoperatively with good breast symmetry, and volume, shape, and ptosis
have been maintained. T is case is interesting or the evolution in the postoperative period. A er the
surgical plan was completed, the patient had a weight loss o 3 kg within 9 months, rom 110 kg to
8 kg. Four years later, the patient developed a very aggressive orm o acial herpes zoster. Steroid ther-
apy caused a new weight gain, to her current weight o 10 kg. T e breasts have ollowed the body weight
changes proportionally, and the le breast, reconstructed signif cantly with adipose tissue, has increased
in volume identical to the contralateral breast.

753
Chapter 41 • Reconstruction o Breast De ormities
TUBULAR BREAST
A
B
C
D

E
Fig. 41-3, A-E
T is 22-year-old woman with bilateral tuberous breasts categorized as Grolleau type III, with severe
breast asymmetry. T e lef breast showed atrophy in all our quadrants. T e in ramammary old was in
a cranial position, with strong adhesion o the tight skin to the chest wall. T e areola was enlarged and
protruding. T e right breast was very lateral and showed atrophy o the lower quadrants, with a high
in ramammary old. T e areola was larger than the contralateral one and less herniated.

754
Part III • Clinical Applications • Breast: Reconstructive
Fig. 41-3, F-I
F
G
I
H
T ree at graf ing sessions were planned. T e use o the BRAVA System be ore and af er each session was
essential or this patient. She wore the device or weeks be ore each procedure. She was taught to tape
the areola o the right breast be ore wearing the device to prevent urther areolar enlargement rom the
negative pressure o the BRAVA device.

755
Chapter 41 • Reconstruction o Breast De ormities
Fig. 41-3, J-L
K
L
J
In the f rst procedure, at was gra ed mostly in the lower quadrants, and debridement rigottomies were
per ormed to lower the in ramammary old. T e patient wore the BRAVA device or 20 days a er sur-
gery, starting week postoperatively. Note the initial f lling o the le breast and lowering o the in ra-
mammary old. On the right side, despite the spread rigottomies, the skin retained the mechanical mem-
ory o the original in ramammary old.

756
Part III • Clinical Applications • Breast: Reconstructive
Fig. 41-3, M-O
M
N

O
T irty days af er the second at graf ing procedure (240 cc), the volume symmetry appeared good. T e
right in ramammary pole was still at, and the original in ramammary old was evident.

757
Chapter 41 • Reconstruction o Breast De ormities
Fig. 41-3, P-R
P
Q

R
T e patient underwent a third at graf ing procedure, with glandular rigottomies. Fat was graf ed in
multiple planes. At -year ollow-up, satis actory breast symmetry, shape, and volume are evident. Both
breasts have a sof , convex lower pole. T e in ramammary old has been lowered to the same level on
both sides.

758
Part III • Clinical Applications • Breast: Reconstructive
POLAND SYNDROME
Fig. 41-4, A-C
A

B
C
T is 1 -year-old patient with Poland syndrome had previously undergone surgery at another hospital
in which an anatomic silicone implant was placed in the right breast in the subcutaneous plane via in-
ramammary old access. She had also, at a pediatric age, undergone endoscopic implantation o metal
devices or the correction o a heart de ect.
T e patient presented requesting breast reconstruction with at gra ing. She had been somewhat satis-
f ed with her previous reconstruction but wanted the prosthesis explanted or ear o breakage. She could
not undergo periodic MRI ollow-up o the implant because o the presence o the cardiac metal device.
She had breast atrophy, absence o the pectoralis major muscle, and absence o the anterior axillary
pillar. She did not have abnormalities in her hand and arm. T ere was a signif cant depression in the
in raclavicular region, and the prof le o the implant was visible. T is de ect was more prominent when
she contracted her pectoral muscles.

759
Chapter 41 • Reconstruction o Breast De ormities
T e prosthesis appeared well positioned; there was mild capsular contracture (Becker type II), and the
position o the in ramammary olds was symmetrical. T e skin was rather elastic and with good thick-
ness, as assessed by pinch test. T e nipple-areola complex o the right breast was hypodeveloped and
slightly lateral, but this did not concern the patient.
Fig. 41-4, D
D
She underwent our sessions o at gra ing over 3 years. We explained to her that only a small amount o
adipose tissue could be harvested each time. T e donor sites were the sacral region and the anks.
Fig. 41-4, E
E
During the f rst at gra ing session the in raclavicular depression was f lled. A total o 2 0 cc o at was
gra ed in the periprosthetic plane between the skin and the capsule. T e skin was released rom the
capsular plane with rigottomies. She was very satisf ed with the immediate improvement o the décolleté
region. A er this f rst session the prof le o the implant was no longer visible.

760
Part III • Clinical Applications • Breast: Reconstructive
Fig. 41-4, F-H
F

G
H
T e patient underwent two subsequent at graf ing sessions, always in the periprosthetic plane (195 cc
and 1 cc). During the third procedure, the breast implant was removed. Well-vascularized viable atty
tissue was visible at the level o in ramammary old during removal o the implant. T e in ramammary
olds were taped and maintained or the next 2 months to stabilize the position o the crease. A ourth at
graf ing session (21 cc) was then per ormed to achieve optimal breast symmetry.

761
Chapter 41 • Reconstruction o Breast De ormities
Fig. 41-4, I-K
I
K
J
At 3-year ollow-up the patient has good breast symmetry. T e in raclavicular region is completely f lled,
and her ribs are no longer visible. T e anterior axillary pillar, which was completely absent at birth, has
been reconstructed without the need or muscle aps. T e patient is very satisf ed with her breast recon-
struction as well as the improvement in body contour rom the liposuction. T e reconstructed breast is
so and has a natural shape.

762
Part III • Clinical Applications • Breast: Reconstructive
C om p l i ca ti on s
T e number o complications in our series has been extremely low. Swelling and ecchymosis are always
present a er surgery but usually resolve within 15 days. T e main long-term complication is the orma-
tion o oily cysts and calcif cations. Eliminating the oily top raction o lipoaspirate rom the syringe a er
harvest and an extremely homogeneous distribution o adipose tissue in microdroplets has allowed us
to gradually reduce the incidence o these complications. In particular, it is essential to avoid placement
o blobs or boluses o atty tissue that would def nitely develop liponecrosis. Any oil cysts diagnosed
ultrasonographically or during physical examination can be aspirated under ultrasound guidance in an
outpatient clinic or in the operating room during a later session o at gra ing.
T e radiologic aspect o calcif cations developed a er at gra ing is always classif ed as Bi-Rads 1 and
Bi-Rads , as large and rim calcif cation. Because o the astonishing growth o at gra ing procedures to
the breast, radiologists have become increasingly skilled at easily di erentiating these images rom the
linear, amorphic microcalcif cation related to breast cancer. Furthermore, we strictly recommend that no
at be gra ed into the mammary parenchyma.
Sometimes a massive improper use o rigottomies can lead to hematoma ormation and the subsequent
resorption o transplanted at. In ectious complications are extremely rare and have never been reported
in our series. All our patients receive a preoperative dose o a prophylactic antibiotic agent.
D i scussi on
By applying our clinical protocol, it is possible to reconstruct even large-volume breasts, obtaining sym-
metry and reducing the need or contralateral reshaping. Reconstruction with gra ed at is permanent,
and the breast tissue increases in size like a normal breast i the patient gains weight. Obviously, the
surgeon must understand the technique per ectly to exploit its ull potential. It is also important to be
patient in staging at gra ing sessions to allow time or the gland, skin, and atty tissue to f nd balance
within the breast.
o promote at take, it is crucial to distribute adipose tissue in several planes to maximize the contact
between adipocytes and capillaries. o enhance engra ment, we place adipose tissue in all available
planes. Subcutaneous distribution o the at is use ul to correct skin irregularities and improve any visi-
ble contour de ect.
T e choice o anatomic planes, the targeted use o rigottomies, the volume o injected lipoaspirate, and
well-planned liposuction and postoperative management contribute to making at gra ing a meticulous,
complex sculptural surgical technique, not a mere f lling o an empty breast.
Percutaneous debridement with a 14-gauge needle o the in ramammary old and at gra ing allows the
surgeon to lower the in ramammary old as much as necessary. Lowering the breast ootprint and repo-
sitioning the areola on top o the breast mound increases mammary projection and creates an evident
reduction o breast ptosis.

763
Chapter 41 • Reconstruction o Breast De ormities
I breast ptosis must be generated, rigottomies in Cooper ligaments in the lower breast pole aid to re-
duce the skin-glandular adhesion. T e glandular weight, no longer supported by the skin, allows the
parenchyma to descend, with skin relaxation and ptosis o the breast. Rigottomies per ormed in the
plane parallel to the skin mantle (two-dimensional rigottomies) allow removal o adhesions that cause
cutaneous retractions. When per ormed perpendicular to the skin (three-dimensional rigottomies) they
allow reduction o skin tension and make space or more at to be gra ed.
T e use o the BRAVA System, when applied consistently and used with adequate compliance by the
patient, provides a better rate o at engra ment. Preoperative application o the BRAVA System osters
angiogenesis that will promote at take a er gra ing, maximizing the rate o survival.3,6 Furthermore,
the negative pressure o the BRAVA dome produces edema within the tissue, resulting in skin relaxation.
T e increase in volume o the breast also acilitates a three-dimensional distribution o at. Postopera-
tively, the negative pressure draws uid and thus osters adipocyte nourishment by di usion. Applica-
tion o the device in the postoperative period helps to consolidate and secure the in ramammary crease
at the right level. T e device must be worn or 0 days postoperatively, leaving a ree period or the f rst
days a er surgery.
C oncl usi on
T e introduction o at gra ing to the breast has certainly revolutionized our approach to the correction
o breast de ormities. T e care ul use o at gra ing and rigottomies has allowed us to treat cases o very
serious breast de ormities in both small and large breasts without the use o glandular aps or breast
implants. T e reconstruction o the anterior axillary pillar with the at in Poland syndrome has made
unnecessary the use o muscle aps, avoiding the well-known complications related to this kind o sur-
gery. T e complication rate with at gra ing is extremely low, limited to large oil cysts that can be easily
resolved with direct aspiration. T e procedure is minimally invasive, does not inter ere with the patient’s
social and working li e, leaves no visible scars, and there is usually an improvement in the contour o the
donor area as well. T e ability to satis y patients’ desires and the minimally invasive approach are con-
sistent with the principles o the reconstructive ladder that should guide our clinical choices toward the
best procedure that is less demanding or the patient and produces the optimal result.
REFERENCES
. Sadove A, van Aalst J. Congenital and acquired pediatric breast anomalies: a review o 20 years’ experi-
ence. Plast Reconstr Surg 5: 0 9, 2005.
2. Rigotti G, Marchi A, Sbarbati A. Adipose-derived mesenchymal stem cells: past, present, and uture. Aes-
thetic Plast Surg :2 , 2009.
. 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. Plast Reconstr Surg 29: , 20 2.
. Khouri R, Khouri R Jr, Rigotti G. Aesthetic applications o Brava-assisted megavolume at gra ing to the
breasts: a 9-year, -patient, multicenter experience. Plast Reconstr Surg : 9 ; discussion 808, 20 .
5. Khouri RK, Rigotti G, Cardoso E, Khouri RK Jr, Biggs M. Megavolume autologous at trans er: part I.
T eory and principles. Plast Reconstr Surg :550, 20 .
. Khouri RK, Rigotti G, Cardoso E, Khouri RK Jr, Biggs M. Megavolume autologous at trans er: part II.
Practice and techniques. Plast Reconstr Surg : 9, 20 .

764
Part III • Clinical Applications • Breast: Reconstructive
. Smith CJ, Khouri RK, Baker J. Initial experience with the Brava nonsurgical system o breast enhance-
ment. Plast Reconstr Surg 110:1593; author reply 1595, 2002.
8. Khouri RK, Rigotti G, Khouri RK Jr, et al. issue-engineered breast reconstruction with Brava-assisted at
gra ing: a -year, 88-patient, multicenter experience. Plast Reconstr Surg 135: 3, 2015.
9. 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 119:1 09;
discussion 1 23, 200 .
10. Rigotti G, Marchi A, Stringhini P, Baroni G, Galiè M, Molino AM, Mercanti A, Micciolo R, Sbarbati A.
Determining the oncological risk o autologous lipoaspirate gra ing or post-mastectomy breast recon-
struction. Aesthetic Plast Surg 3 : 5, 2010.
11. Rigotti G. Discussion: T e volumetric analysis o at gra survival in breast reconstruction. Plast Reconstr
Surg 131:192, 2013.
12. Khouri RK, Smit JM, Cardoso E, Pallua N, Lantieri L, Mathijssen IM, Khouri RJ Jr, Rigotti G. Percutane-
ous aponeurotomy and lipof lling: a regenerative alternative to ap reconstruction? Plast Reconstr Surg
132:1280, 2013.
13. Rigotti G, Marchi A, Khouri R. Minimally invasive autologous mastectomy incisionless reconstruction:
external expansion at gra ing and percutaneous scar release: a multicenter experience. Presented at the
Eighty-eighth Annual Meeting and Symposium o the American Association o Plastic Surgeons, Rancho
Mirage, CA, Mar 2009.

Fat Gr a t ing or Br east
Reconst r uct ion Wit h E t er nal
Vacuum E pansion
Daniel Calva, Roger K. Khouri
T d v x v x b d
-d v z d f d. T k x d y k
v w b , d , -
w , v , d v .1-7 O w b f d b
x d d d d, v d d
b j d y d f d w . T d b -
w f d.8
Fig. 42-1, A
Week 1
A
Week 2

Week 3
C h a p t e r 4 2
765

766
Part III • Clinical Applications • Breast: Reconstructive
Fig. 42-1, B
B
After autologous fat grafting
T e tissue sca old is created using an external vacuum expansion (EVE) technique in which new stro-
mal and vascularized tissues are generated. It can be seen how the small droplets o at f ll the small
spaces created and will eventually undergo revascularization.
For more than 0 years, the second author (R.K.) has o ered this alternative to autologous ap recon-
struction. Our recently published multicenter study o 488 patients showed that external tissue expan-
sion with subsequent autologous at gra ing is a sa e, e ective, and minimally invasive method o breast
reconstruction that is per ormed on an outpatient basis.9-11
In this chapter we will discuss patient selection and preparation or the procedure, surgical techniques
or both immediate and delayed reconstruction, clinical outcomes and complications, and cost analysis
o the procedure compared with autologous ap reconstruction.
P a ti ent S el ecti on a n d P re p a ra ti on
T e ideal patient has moderate at deposits and nonirradiated, unscarred breast tissue, and is a non-
smoker with realistic expectations. We still consider patients with a low BMI who have previously irra-
diated breasts or scarring to be good candidates or the procedure. However, the procedure will require
signif cantly more e ort, time, and expertise in these patients, and it should there ore be approached
with more caution. Our exclusion criteria include smoking, bleeding disorders, skin conditions that lead
to deepithelialization (such as epidermolysis bullosa and pemphigus), an active skin in ection where the
expansion device will be placed, and patients with unrealistic expectations.
T e expansion process and the time rame involved must be thoroughly discussed during the initial con-
sultation with the patient, because patient compliance is essential to the success o the procedure. T e
EVE device is placed on the patient and activated in the o ce; it is tested or approximately 20 minutes
to make certain that the patient can tolerate it.

767
Chapter 42 • Fat Gra ting or Breast Reconstruction With External Vacuum Expansion
T e EVE device must be used with cycling pressures o 0 to 0 mm Hg or 3 minutes on and 1 minute
of or 10 hours per day, starting to 3 weeks be ore autologous at gra ing is per ormed. T e minimum
therapeutic dose is arbitrarily set at 00 hours to be accumulated over the approximately 15 days just
be ore gra ing.
Fig. 42-3
T is patient shows how the EVE process progresses during breast reconstruction. She is seen be ore and
3 weeks a er external tissue expansion o her postmastectomy breast mounds.
Patients are considered ready or at gra ing when their breast mound volume is at least .5 times
greater than their preexpansion volume. We educate the patient to understand that she is responsible or
her results—the greater the expansion, the better the result. Fat will lodge and survive in a preexpanded
scaf old, but it cannot expand the tissues and survive at the same time.
Fig. 42-2
T is patient shows how the EVE device is positioned
and used by the patient. T is woman had undergone bi-
lateral mastectomy. T e irradiated right breast required
more gra ing sessions; her le nonirradiated breast has
already undergone an immediate reconstruction, ex-
ternal volume expansion, and autologous at gra ing
(AF ).

768
Part III • Clinical Applications • Breast: Reconstructive
S ur g i ca l T ech ni q ues
FAT HARVEST
Fig. 42-4
We use the Lipogra er, K-VAC syringe, and A valve (Marina Medical) devices, which maintain the
aspirated at in a closed system throughout the procedure. wo surgeons can harvest at simultaneously,
a major advantage. Above, two bags containing lipoaspirate are shown in two di erent stages; in the
nearer bag the at has been separating by gravity sedimentation or 10 minutes, whereas the posterior
bag was just f lled.
T e identif ed donor sites are marked preoperatively. A er general anesthesia is induced, the harvest ar-
eas are inf ltrated with tumescent solution containing 1:100,000 o epinephrine until the tissues are very
f rm. We typically in use 1 to 2 L per side per area to be liposuctioned. We attach the Lipogra er to a 12-
hole, 12-gauge cannula that is connected to the K-VAC syringe. T e syringe provides a constant vacuum
pressure o 300 mm Hg as it harvests at, with no need to switch syringes or use multiple syringes at any
point. T e K-VAC e ciently and atraumatically drives the harvested at into the sterile bag through the
our-way atraumatic A valve.8 T e at remains in this closed system throughout; this minimizes its ex-
posure to the environment and adheres to the accepted principles o at gra ing. As the at is trans erred
to the sterile bag, at the same time the K-VAC syringe automatically gets recocked to create the constant
300 mm Hg o pressure.

769
Chapter 42 • Fat Gra ting or Breast Reconstruction With External Vacuum Expansion
LIPOASPIRATE PREPARATION
Once the sterile bag is f lled with lipoaspirate to its total 00 cc capacity, it is centri uged at 15 g or
1 minute, or it is allowed to separate by gravity (1 g) or 15 minutes. T ere is almost no ree oil noted in
the bag when this gentle technique is used. T e tumescent uid is drained out o the bag, and the at is
ready or gra ing.
GRAFTING
T is patient has been prepared or at gra ing, with markings
on the skin to show the multiple planes and passes needed to
distribute the at evenly throughout the externally expanded
mastectomy mound.
Fig. 42-5
T e increased recipient site volume a er expansion provides the necessary additional gra ing capacity.
T e amount o at that can be gra ed is determined by this added capacity and the mechanical com-
pliance o the original recipient site. T e gra ed at must be di usely dispersed as a f ne mist o micro-
droplets or as ribbons that are no wider than mm and that do not coalesce into larger blobs, which
could lead to necrosis. We there ore inject the gra through multiple 1 -gauge needle puncture holes
all around the mastectomy site. With this system o minute amounts o at, we aim to achieve evenness
through randomness. We pre er to use a single-hole curved cannula with a spatulated tip that ollows the
contour o the breast curvature; by keeping the tip pointing upward, this best prevents inadvertent chest
wall puncture.
Microdroplets o lipoaspirate are delivered with a small .5 cc syringe using long passes o a 5 cm
long, . mm diameter cannula. Delivering 0.1 cc/cm leaves behind mm wide ribbons throughout the
breast as the cannula goes through contiguous arcuate sweeping passes in multiple layers, rom deep to
superf cial. T e our-way A valve allows the syringe to automatically draw the at in rom the bag, then
back out through the gra ing cannula. T e economy o motion a orded by avoiding cannula switching
and syringe reloading saves time while allowing the surgeon to precisely deliver the gra through small
syringes.
Fig. 42-6
T e at is dispersed rom the same bag that was used
to harvest the at. T is technique ensures even de-
livery and avoids large droplets, which can coalesce
into lakes that may lead to at necrosis or oil cysts.

770
Part III • Clinical Applications • Breast: Reconstructive
It is crucial to avoid overgra ing which will lead to increased interstitial pressures that choke circulation
and prevent revascularization o the at.12-13
P osto p era ti ve C a re
On postoperative day or , the patient will start to use the EVE device at a low constant pressure o
mm Hg or as many hours per day as can be tolerated or to weeks. T e use o the device at this
point helps create a three-dimensional stent to immobilize the at gra s and keep the breast’s biologic
sca old in the expanded state. Alternatively, we place an immobilizing con orming adhesive splint over
the breast to maintain the expanded, gra ed state and to prevent it rom de ating or a ew weeks.
T e entire process can be repeated a er or months until the reconstructed breast mound has satis-
actory projection. For bilateral reconstructions, the goal is to achieve a symmetrical result that satisf es
both the patient and the surgeon. For unilateral reconstructions, the goal is to achieve symmetrical vol-
ume and contour with the contralateral breast. For irradiated breasts, there should be at least a -month
interval between gra ing sessions.
A d d i ti ona l M
a neuvers
For breast tissue that is scarred, we employ the percutaneous aponeurotomy and lipof lling (PALF) pro-
cedure (see Chapter ). T is technique releases the contractures by percutaneously mesh-expanding
the scars and gra ing at in the tiny three-dimensional gaps created by the needle release. T e cicatrix
becomes the matrix, and the hard, f brous scar is so ened by myriad at microgra s lodged inside. Fur-
thermore, the interspersed at prevents the divided f bers rom reconnecting, reducing the risk o con-
tracture recurrence.14
D el a yed R econ structi on
Fig. 42-7, A and B
Postmastectomy
A
B
T is patient underwent bilateral mastectomies and ailed immediate implant reconstruction. She had a
low BMI and presented with open wounds.

771
Chapter 42 • Fat Grafting for Breast Reconstruction With External Vacuum Expansion
She underwent three sessions of external expansion plus AFT. Her results at 3-year follow-up show a
healed and satisfactory result.
Fig. 42-7, C-J
After expansion/AFT 1
C

D
After expansion/AFT 2
E
F
After expansion/AFT 3
G
H
Result at 3 years
I
J

772
Part III • Clinical Applications • Breast: Reconstructive
External expansion increases the volume o the mastectomy de ect, enlarges the biologic sca old, and
stimulates the genesis o new stromal and vascular elements. External expansion allows more gra to
survive per session and undoubtedly reduces the number o at gra ing sessions required or an accept-
able whole breast reconstruction.8
Many patients undergo mastectomy without immediate reconstruction. T e last thing some o these
women want to think about at the time o cancer treatment is undergoing another invasive procedure.
Breast reconstruction with AF lowers the acceptance threshold or mastectomy reconstruction at a later
date. Delayed reconstruction is the sa er option or patients who might undergo radiotherapy, because it
would be a waste to irradiate the at gra ed tissue. In mastectomy patients who have undergone radiother-
apy, poor tissue compliance limits expansion and restricts the amount o at that can be sa ely gra ed per
reconstructive procedure.15-16 It is not until the third gra ing session that the tissue o the irradiated de ect
takes on a more normal structure and can be treated like the tissue o a nonirradiated mastectomy patient.
I mmed i a te R econ structi on
raditional at gra ing is a blind procedure: we cannot see the at coming out o the cannula, and we
are not sure that we are avoiding excess localized deposits. Immediate reconstruction provides a unique
opportunity to per orm three-dimensional gra ing under direct vision.
T e technique o gra ing into the pecto-
ralis major muscle is shown, with clinical
photographs o the thin ribbons o at that
are placed both intramuscularly and sub-
muscularly.
T e recipient site in standard at gra ing
has a limited capacity. With the pectoral as-
cia removed, the muscle can swell to many
times its original volume without increasing
the interstitial tissue pressure. T e pectoralis
major muscle is completely exposed in this
situation, and the plastic surgeon can gra
autologous at under direct vision to the en-
tire muscle.
T e idea is to gra f ne ribbons o at between the muscle ascicles (intramuscular) in multiple planes, rom
deep to superf cial. Fat can also be deposited submuscularly, but one should always exercise caution to
avoid penetrating the intercostal muscles with the cannula to prevent a pneumothorax. Depending on the
size o the muscle, 00 to 400 cc o at can be gra ed immediately within the muscle, the lateral thoracic
ascia, and, i possible, the base o the mastectomy aps.
In contrast to traditional procedures, and somewhat counterintuitively, excess skin is a problem in AF
total breast reconstruction. Excess skin accordions into olds, with troughs that adhere to the chest and that
become extremely di cult to release without creating ischemia or cavities where the at gra s will die. T e
mastectomy skin ap closure should be loose, just right, and with no old. In immediate AF reconstruc-
tion, trimming or keeping the excess skin is a variable that is best controlled by the plastic surgeon.
Fat can also be gra ed under direct vision into the subcutaneous tissues o the mastectomy aps, espe-
cially in the upper pole, where the plastic surgeon can start to shape the breast. Patients will immediately
Fig. 42-8

773
Chapter 42 • Fat Gra ting or Breast Reconstruction With External Vacuum Expansion
have a small breast and can show some cleavage as the at gra ed pectoralis muscle swells up the medial
and upper part o the thorax. T is reduces some o the psychological trauma associated with mastecto-
mies. I the patient’s tumor biology is such that she will undergo radiotherapy, immediate reconstruction
is not of ered, since the radiation will undoubtedly injure the gra ed at and compromise the results.
By to 6 weeks a er the mastectomy, the skin aps have healed, the gra ed at has revascularized and
is now adhered to the muscle, and the patient is ready or external volume expansion. o create a large
enough biologic scaf old by expansion, a total o one to six additional procedures will likely be required
to complete the entire whole breast reconstruction. One should adhere to the principles described in the
sections on surgical techniques or each additional procedure and expansion.
Before removal of silicone implants
Intraoperative images show loss of volume
1 year postoperatively
Fig. 42-9
T is woman requested removal o her silicone breast implants and immediate total breast reconstruc-
tion. Intraoperatively, the loss o volume a er implant removal is evident. She underwent only one gra -
ing session. Her result is seen 1 year postoperatively.

774
Part III • Clinical Applications • Breast: Reconstructive
Another scenario in which immediate breast reconstruction with AF can be achieved is when an im-
plant is removed or a number o reasons, such as capsular contraction, in ection, or other complica-
tions. In such cases, total breast reconstruction can be achieved in one AF session, which is carried out
in the same procedure in which the implant is removed.
C l i ni ca l E x p eri ence
We prospectively tracked patient demographics, the volume gra ed, the number o reconstructive pro-
cedures per patient, complications, and breast cancer recurrence in a -year series o 88 patients.11 Pre-
operative and f nal breast volumes were calculated using three-dimensional sur ace imaging and MRI.17
In terms o demographics, the average BMI was 23.5 (range 5 to 3 ), and an average age at the f rst
reconstructive procedure o 5 years (range 28 to ). In years, a total o 88 patients underwent recon-
struction, with a mean ollow-up o 2.5 years (range 6 months to years). A total o 8 sessions o at
gra ing were per ormed in 6 6 breasts. From the 88 patients, in 2 o them their reconstruction was
completed (8 .5%), or a total o 90 reconstructive operations in 568 breasts.
We per ormed immediate breast reconstruction on 80 breasts; 2 o these had been treated with prophy-
lactic mastectomies. Patients who did not undergo radiotherapy required an average o 2. procedures
to reach a satis actory result (range to 5); with irradiated patients an average o .2 gra ing sessions
were needed (range 2 to ). A total o 39 breasts underwent delayed reconstruction, with o them
having at least one previous reconstruction ( ap or implant based) that had ailed. For the delayed re-
construction nonirradiated patients, an average o 2.8 procedures were needed to complete a satis actory
reconstruction (range 2 to 6). In contrast, or delayed irradiated patients, an average o .9 procedures
were needed (range 3 to 0). Patients who had prior reconstruction with implants or aps accounted or
the higher number o reconstructive procedures needed to achieve a satis actory result.
Fig. 42-10
MRIs o this patient who underwent total breast reconstruction are shown be ore and year a er re-
moval o her implants. We then per ormed expansion/AF reconstruction. T ere are no oil cysts, no
evidence o at necrosis, or changes in her breast architecture. Notice that the overall breast volume has
been maintained.

775
Chapter 42 • Fat Gra ting or Breast Reconstruction With External Vacuum Expansion
T e average volume o at gra ed per session was cc per breast, and on average the f nal breast
mound volume achieved, measured by MRI, was 3 cc per breast. Initially, because o scarring and
poor compliance o the skin envelope a er radiotherapy, we could gra only small amounts. However,
as the breast mound became larger and more compliant a er at gra ing and EVE, the volumes o at
gra ed were higher.
All patients with nonirradiated breasts recovered the ability to sense the light touch o a cotton wisp over
their entire reconstructed breast. Ninety percent o patients reported high satis action with the volume,
contour, and general eel o their breasts. All patients returned to work a er their f rst postoperative visit
( days) without any problems. T e subset o nonirradiated patients who underwent immediate recon-
struction had better overall results. Patients in this cohort underwent ewer reconstructive procedures
and had ewer complications compared with patients who received radiotherapy, and underwent delay
reconstruction. Patients who underwent skin-sparing and/or nipple-sparing mastectomies had higher
complications in terms o excess mastectomy skin ap that olded and adhered to the chest wall. T e
olds were di cult to release, which compromised the end results in volume, overall contour, and shape.
C om p l i ca ti on s
Immediate complications in our series occurred within the f rst 30 days and included a total o pneu-
mothoraces (0.8%), patients with uncomplicated bacterial cellulites that improved with antibiotics
(0.3%), and 18 cases o skin necrosis, which included pressure ulceration and mastectomy ap necrosis
( .9%). T ere were signif cantly greater rates o skin necrosis on irradiated breasts (6. %) than on non-
irradiated breasts (1. %; p < 0.01).
Table 42-1 Complication Rates Over 7 Years in 1877 Procedures in 616 Breasts
Immediate Reconstruction

Delayed Reconstruction
Complication

No Irradiation (%) Irradiation (%) No Irradiation (%) Irradiation (%) Overall
Palpable masses

13

38

1

3

3
Pneumothorax

1.

0

0

1.9

0.8
In ection

0

13

0

0

0.3
Skin necrosis

.8

13

1.1

.8

.9
Recurrence

0

0

0

0.6

0.
Most cases o necrosis occurred in the early parts o the senior author’s experience. As the learning curve
improved regarding how much at gra ing a recipient site can tolerate, and with the use o PALF to
release scar tissue, pressure-related skin necrosis was avoided. T e incidence o pneumothorax in tradi-
tional primary breast augmentation is higher than the reported incidence o pneumothorax in this study.
For long-term complications, palpable masses were noted in 1 % to 13% o nonirradiated breasts and
3 % to 38% o irradiated breasts. On ultrasonography, most masses were ound to be lipid cysts. Solid
masses were evaluated by MRI, and most were consistent with benign processes such as at necrosis.
However, we per ormed biopsies on suspicious masses ( . %), and locoregional recurrences were diag-
nosed in three patients (0. %).

776
Part III • Clinical Applications • Breast: Reconstructive
D i scu ssi on
Breast reconstruction with external expansion and AF is in vivo tissue engineering. External expansion
generates the Holy Grail o tissue engineering: a three-dimensional biologic sca old with a unctional
capillary circulation. Seeding this sca old with AF regenerates an in situ bloc o living autologous
tissue that eels like, looks like, and maintains the natural properties o a breast.19 In contrast to ap re-
construction, which involves complex, lengthy, and complication-prone procedures, external expansion
with AF gives the patient re-created volume with the use o her own tissue.
Patients who undergo ap reconstruction spend considerably more time in the hospital and incur sig-
nif cantly higher costs. RAM and DIEP ap reconstructions behave and look better than implant-based
reconstructions; however, these patients will have large scars in the breasts as well as at the donor sites.
In an implant-based reconstruction the patient is given an inert, insensate, and complication-prone or-
eign body. I (R.K.) championed the ap procedures or breast reconstruction until I realized the clear
superiority o external expansion with AF .
Remaining mind ul o the principles o at gra ing to maximize gra survival is important. T e f rst,
the gra -to-recipient inter ace, is a key actor and dictates that at gra s must be small enough (approxi-
mately mm) to allow all injected at to be in contact with the vascular sca old. T e principle governing
recipient size limitations states that one cannot gra more than what the biologic sca old can support.
T ere have been many attempts to use additives and at preparations to try to overcome these two prin-
ciples, but the long-term outcomes are disappointing.20,21 Without preexpansion, the rate-limiting step
in the reconstruction is the small amount o space that can be gra ed.22 By using an EVE device, the bi-
ologic sca old is increased, and the genesis o new stromal and vascular elements not only supports the
enlarging sca old but also supports larger amounts o gra ed at. EVE increases the recipient size limits
and ultimately leads to a large gra -to-recipient inter ace.2,8,10
wo additional techniques need to be care ully considered or dealing with the scar release and the ex-
pansion o the skin envelope. T e PALF technique aids the surgeon not only in scar release, but also in
expanding the skin envelope to release the tension and minimize the increase in interstitial pressures in
at gra ing. By per orming percutaneous rigottomies in a meticulous and organized matter, the surgeon
can convert a restrictive cicatrix into a three-dimensional matrix sca old that can host large amounts
o gra ed at in an environment poised or success.13,14 T ere is a delicate balance between adequately
gra ing and overgra ing the recipient inter ace, and as already discussed, the surgeon must resist the
temptation to gra an excessive amount o lipoaspirate. An easy way to make certain that the interstitial
pressures are not elevated is to use a -gauge needle connected to an arterial line monitor and measure
the compartment pressures within the breast. Another important technique to keep in the tool box is
the reverse abdominoplasty with at trans er (RAF ), which allows recruitment o upper abdominal
skin to create the lower pole o the breast and re-create the in ramammary old. T is procedure not only
increases the breast envelope’s total sur ace area, but also allows larger amounts o at to be gra ed sa ely
without increasing the interstitial pressure levels.23
T e use o these two techniques, in combination with EVE, has allowed us to increase the average
amount o at gra ed to the breast in our cohort o patients. In our cohort, the average gain in volume
measured by three-dimensional imaging and MRI was 5 cc, compared with the average published
results o cc to 5 cc.24-27 As a result o the increased survival o autologous at that can be achieved,
patients undergo ewer procedures (an average o . sessions in nonirradiated breasts and . sessions
in irradiated breasts) compared with other traditional reconstruction procedures ( .5 sessions). We con-
sider only meaning ul volume gain as the most accurate outcome measurement, which is the percentage
augmentation o the recipient site compared with the preaugmentation volume.7,8,26

777
Chapter 42 • Fat Gra ting or Breast Reconstruction With External Vacuum Expansion
Complications rom EVE with AF reconstruction were lower than with any other technique. T ere
was a rate o . % o skin ulceration and mastectomy ap necrosis, which improved signif cantly over
the learning curve. A rate o less than % o pneumothorax, in ection, and locoregional recurrences was
observed; this is well below the published averages with other procedures o whole breast reconstruc-
tion.18,24-27 Other groups have also reported a lower than average complication rate using EVE with the
AF technique or breast reconstruction.28,29
Most complications occur in patients undergoing reconstruction a er postmastectomy radiotherapy. A
report by Uda et al30 showed that their outcomes using expansion with AF can be replicated, with low
complication rates. However, they concluded that the technique should be contraindicated in patients
who had undergone radiotherapy because o the higher associated levels o complications. We disagree
with the statement that patients who have undergone radiotherapy should not undergo tissue expansion
with at gra ing. T ere is enough evidence in the literature that argues the positive e ects o at gra ing
to the irradiated skin aps in terms o reversing the adverse e ects.15 It is important to recall that irradi-
ated tissue does not behave like normal tissue; it cannot be gra ed like nonirradiated tissue until at least
three at gra ing sessions have reversed the damage rom irradiation and the trans erred adipose tissue
has repopulated the irradiated f eld with enough healthy tissue to respond normally.
We ound an overall low rate o palpable masses in our series: % in nonirradiated breasts and %
in irradiated breasts, most o which were benign (locoregional recurrence . %). T is incidence is not
higher than what has been published with other techniques in breast reconstruction or in traditional
breast reduction procedures.31,32 T e psychological burden on the patient o eeling a new mass when
she is undergoing reconstruction or breast cancer is a devastating discovery that cannot be dismissed
lightly. T e low rate o locoregional recurrence ( . %) a er tissue expansion with at gra ing supports
the utility o this technique over others. Studies have ound no evidence o increased rates o breast can-
cer in patients undergoing at gra ing or breast reconstruction, but we approach every newly palpable
mass with a high index o suspicion.33-36
One o the major advantages o external volume expansion ollowed by at gra ing is that breast sen-
sation is preserved. It is very di cult to explain the reasons or such results without invasive studies
assessing the cutaneous nerves under the microscope with special stains. However, we hypothesize that
because the process o tissue expansion is prolonged over a period o weeks, the nerves have the ability
to stretch, adapt, and maintain unction.
Finally, a cost analysis o EVE over other techniques such as implant-based reconstruction or aps shows
that there is not only a cost benef t to the individual but to society in general. Current Medicare esti-
mates show that in comparison with other techniques, EVE with at gra ing would save $ . billion
dollars annually. T ese savings do not take into account the multiple procedures needed in other recon-
structions, the multiple implants that will be exchanged in the patient’s li etime, and the higher levels o
complications associated with DIEP, RAM, and implant-based reconstruction.
C oncl usi on
Breast reconstruction with EVE and AF is about adhering to strict undamental principles. By creat-
ing an in situ vascularized biologic sca old, this is tissue engineering. T e sca old in turn supports the
survival o care ully distributed at droplets harvested with the most gentle o techniques. T e result is
a beauti ul, natural, sensate, atty breast that the patient regenerates in situ through the expansion pro-
tocol ollowed in her own home. Although it does require multiple procedures, these are all outpatient,
minimally invasive, and with low complications. T e results are long-lasting, and patients are extremely
satisf ed. We conclude that breast reconstruction with external expansion and AF costs less and is su-
perior to other alternatives.

778
Part III • Clinical Applications • Breast: Reconstructive
REFERENCES
1. Khouri RK, Schlenz I, Murphy BJ, et al. Nonsurgical breast enlargement using an external so -tissue ex-
pansion system. Plast Reconstr Surg 105:2500, 2000.
2. Khouri R, Del Vecchio D. Breast reconstruction and augmentation using pre-expansion and autologous
at transplantation. Clin Plast Surg 36:269, 2009.
3. Chin MS, Ogawa R, Lancerotto L, et al. In vivo acceleration o skin growth using a servo-controlled
stretching device. issue Eng Part C Methods 16:39 , 2010.
4. Liu PH, Lew DH, Mayer H, et al. Micro-mechanical orces as a potent stimulator o wound healing. J Am
Coll Surg 199:5 , 2004.
5. Heit YI, Lancerotto L, Mesteri I, et al. External volume expansion increases subcutaneous thickness, cell
proli eration, and vascular remodeling in a murine model. Plast Reconstr Surg 130:1, 2012.
6. Lancerotto L, Chin MS, Freniere B, et al. Mechanisms o action o external volume expansion devices.
Plast Reconstr Surg 132:569, 2013; reply 133:426e, 2014.
. Khouri RK, Rigotti G, Cardoso E, et al. Megavolume autologous at trans er: part I. T eory and principles.
Plast Reconstr Surg 133:550, 2014.
. Khouri RK, Rigotti G, Cardoso E, et al. Megavolume autologous at trans er: part II. Practice and tech-
niques. Plast Reconstr Surg 133:1369, 2014.
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, 1-patient, prospective multicenter study. Plast Re-
constr Surg 129:11 3, 2012.
10. Khouri RK, Khouri RK Jr, Rigotti G, Marchi A, Cardoso E, Rotemberg SC, Biggs M. Aesthetic applica-
tions o Brava-assisted mega-volume at gra ing to the breasts: a 9-year, 4 6-patient, multicenter experi-
ence. Plast Reconstr Surg 133: 96, 2014.
11. Khouri RK, Rigotti G, Khouri RK Jr, Cardoso E, Marchi A, Rotemberg SC, Baker J, Biggs M. issue-
engineered breast reconstruction with Brava-assisted at gra ing: a -year, 4 -patient, multicenter expe-
rience. Plast Reconstr Surg 135:643, 2015.
12. Milosevic MF, Fyles AW, Wong R, et al. Interstitial uid pressure in cervical carcinoma: within tumor
heterogeneity, and relation to oxygen tension. Cancer 2:241 , 199 .
13. Milosevic MF, Fyles AW, Hill RP. T e relationship between elevated interstitial uid pressure and blood
ow in tumors: a bioengineering approach. Int J Radiat Oncol Biol Phys 43:1111, 1999.
14. Khouri RK, Smit JM, Cardoso E, et al. Percutaneous aponeurotomy and lipof lling: a regenerative alterna-
tive to ap reconstruction? Plast Reconstr Surg 132:12 0, 2013.
15. Rigotti G, Marchi A, Galie 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 119:1409,
200 .
16. Mojallal A, Lequeux C, Shipkov C, et al. Improvement o skin quality a er at gra ing: clinical observa-
tion and an animal study. Plast Reconstr Surg 124: 65, 2009.
1 . Kovacs L, Eder M, Hollweck R, et al. Comparison between breast volume measurement using 3D sur ace
imaging and classical techniques. Breast 16:13 , 200 .
1 . Schneider LF, Albornoz CR, Huang J, et al. Incidence o pneumothorax during tissue expander-implant
reconstruction and algorithm or intraoperative management. Ann Plast Surg 3:2 9, 2013.
19. American Medical Association. ICD-9-CM Expert or Hospitals and Payers, vols 1 through 3, Pro es-
sional Edition 2016. Chicago: T e Association, 2016.
20. Salgarello M, Visconti G, Rusciani A. Breast at gra ing with platelet-rich plasma: a comparative clinical
study and current state o the art. Plast Reconstr Surg 12 :21 5, 2011.
21. Zhao J, Yi C, Zheng Y, et al. Enhancement o at gra survival by bone marrow-derived mesenchymal
stem cell therapy. Plast Reconstr Surg 132:1149, 2013.
22. Delay E, Garson S, ousson G, et al. Fat injection to the breast: technique, results, and indications based
on 0 procedures over 10 years. Aesthet Surg J 29:360, 2009.

779
Chapter 42 • Fat Gra ting or Breast Reconstruction With External Vacuum Expansion
3. Khouri RK, Cardoso E, Rotemberg S. T e reverse abdominoplasty and at trans er (RAF ) procedure: a
minimally invasive, autologous breast reconstruction alternative. Presented at the wenty-f h Meeting
o the European Association o Plastic Surgeons (EURAPS), Isle o Ischia, Italy, May 01 .
. Delaporte , Delay E, oussoun G, et al. Breast volume reconstruction by lipomodeling technique: about
15 consecutive cases. Ann Chir Plast Esthet 5 :303, 00 .
5. Doren EL, Parikh RP, Laronga C, et al. Sequelae o at gra ing postmastectomy: an algorithm or manage-
ment o at necrosis. Eplasty 1 :e53, 01 .
6. Choi M, Small J, Levovitz C, et al. T e volumetric analysis o at gra survival in breast reconstruction.
Plast Reconstr Surg 131:185, 013.
. Losken A, Pinell XA, Sikoro J, et al. Autologous at gra ing in secondary breast reconstruction. Ann Plast
Surg 66:518, 011.
8. Seth AK, Hirsch EM, Kim JY, et al. Long-term outcomes ollowing at gra ing in prosthetic breast recon-
struction: a comparative analysis. Plast Reconstr Surg 130: 8 , 01 .
. Claro F, Figueiredo JC, Zampar AG, et al. Applicability and sa ety o autologous at or reconstruction o
the breast. Br J Surg : 68, 01 .
30. Uda H, Sugawara Y, Sarukawa S, et al. Brava and autologous at gra ing or breast reconstruction a er
cancer surgery. Plast Reconstr Surg 133: 03, 013.
31. Casey WJ, Rebecca AM, Silverman A, et al. Etiology o breast masses a er autologous breast reconstruc-
tion. Ann Surg Oncol 0:60 , 013.
3 . Mandrekas AD, Assimakopoulos GI, Mastorakos DP, et al. Fat necrosis ollowing breast reduction. Br J
Plast Surg :560, 1 .
33. Fraser JK, Hedrich MH, Cohen SR. Oncologic risks o autologous at gra ing to the breast. Aesthet Surg
J 31:68, 011.
3 . Ihrai , Georgiou C, Machiavello JC. Autologous at gra ing and breast cancer recurrences: retrospective
analysis o a series o 100 procedures in 6 patients. J Plast Surg Hand Surg : 3, 013.
35. Petit JY, Lohsiriwat V, Clough KB, et al. T e oncologic outcome and immediate surgical complications o
lipof lling in breast cancer patients: a multicenter study—Milan-Paris-Lyon experience o 6 6 lipof lling
procedures. Plast Reconstr Surg 1 8:3 1, 011.
36. Brenelli F, Rietjens M, De Lorenzi F, et al. Oncological sa ety o autologous at gra ing a er conservative
breast treatment: a prospective evaluation. Breast J 0:15 , 01 .

(Trang không có chữ)

UPPER EXTREMITY
S e c t i o n S i x

(Trang không có chữ)

C h a p t e r 4 3
A esth eti c C on si d era ti on s
T h s s bl cl h s h h b y h f s s sh w s g s
g g. Al h gh s phys c s b l h b c s s l s w h g g, pl c g
h s h g g h s j s f bl , b s h s ss g h l h .
T s h l h s p s y , c y g h s ll,
. T k y s cc ss l j h g g h s c g l y
g s h s l h h k s h sk l k l h ck , w h sl gh s bc s
ll ss.
T s c , h l hy- pp g h h s sl gh s bc s ll ss h
bsc s s s b s h h . T s f wh h
c p ph l g l (MCP) j s h w s x h wh h y x
p s . T s p f c l s s lly sc bl , h sl hl c -
l, h l g s c h s s pp . T bl c l h s c b s
h gh h sk , b h wh c l s s lly sc bl . T s g l z
ll ss h sk s bc s ss s h s l h b y h s
h j s w h y h l ll ss.
Hand and For ear m
Re uvenat ion
Sydney R. Coleman
783

784
Part III • Clinical Applications • Upper Extremity
Age 22
A
Age 57
B
Age 22
C
Age 57
D
Fig. 43-1, A-D
T e tendon area is clearly visible in the photos o this patient taken when she was 22 years old. T ere
is a hint o veins visible through the skin, especially around the proximal phalanges and over the index
metacarpal. By age 5 , the subcutaneous structures o her hand are more visible with the skin o the
dorsal hand clinging to the tendons and most o the circum erence o the veins protruding rom o
the conf nes o the hand. As the ullness is lost, the joints appear larger and become more def ned. T e
thumb MCP and proximal interphalangeal (PIP) joints appear especially large compared with the earlier
photo o her hand.
Fig. 43-1, E and F
E
F
As the ullness o the hand is lost with advancing age, the joints become more isolated. T e veins are
more obvious both in shape and color and the tendons’ whiteness glistens more through the thinning
skin. Subtle ullness over the hands and f ngers is the element missing rom the older hand.

785
Chapter 43 • Hand and Forearm Rejuvenation
Fig. 43-2
In the aging hand, generalized subcutaneous ullness gradually disappears as the subcutaneous tissues and
skin atrophy. With loss o ullness, the veins appear more prominent, their blue color deepens, and the
extensor tendons appear whiter and more visible through the thin skin o the dorsal hand. T e tendons
are prominent even at rest or with exion o the MCP joints. With the loss o supporting ullness under
the dermis and a gradual diminution o elasticity, the skin’s texture becomes more crepey and wrinkled.
Fig. 43-3
T e intermetacarpal spaces deepen, especially between the thumb and the index f nger, and there is
some loss o intrinsic muscle volume. As the ullness o the hand is lost, the f ngers and joints may ap-
pear enlarged and arthritic.

786
Part III • Clinical Applications • Upper Extremity
T e objective o hand rejuvenation with Coleman at gra ing is to restore a youth ul ullness to the back
o the hand by placing a thin layer o ullness in the subdermal plane and, over time, creating a thicken-
ing o the skin.
T e simple, reliable technique o autologous structural at gra ing can be used to achieve long-lasting
rejuvenation o the dorsum o the hand. With this approach, restoring a slight ullness to atrophic subcu-
taneous tissue and thickening o the skin rejuvenates the dorsal hand; this also so ens the color, masks
the exposed extensor tendons and veins, and supports the aging skin.
A n a tomi c C on si d era ti on s
T e potential or damage to underlying structures is minimal so long as only a type I cannula (the blunt-
est) is used at all times. With purpose ul placement in the subdermal layer between the veins and skin,
ew anatomic structures are exposed to trauma. Even the trauma to the veins is so minimal with this
technique that I have only rarely seen signif cant bruising a er structural at gra ing to the dorsum o
the hand. T e main potential anatomic problems can be created by the manipulation o at a er place-
ment. Strong digital pressure on a clump o at might push the newly gra ed tissue deep to the tendons
or even deeper into the intrinsic muscles o the hand (see Complications).
T e key to structural at gra ing o the dorsum o the hand is purpose ul placement o a smooth layer o
tissue against the undersur ace o the dermis, with extra placement into def cient intermetacarpal and
web spaces.
I n d i ca ti on s a n d P a ti ent S el ecti on
ypically, patients who present or at gra ing to the hand complain that their hands make them appear
older than their aces would suggest. T ey point to the dorsum o their hands, where the veins and ten-
dons have become more prominent, and request a uller, more youth ul look. Individuals with noticeable
loss o subcutaneous ullness o the dorsal hand and apparent thinning o the skin are the best candidates
or hand rejuvenation with at gra s. T ese patients usually also have prominent underlying veins and
tendons along with an increase in the crêpiness o the skin. Patients with intermetacarpal wasting or
arthritis are also candidates or this procedure, because adjustment o the volume proportions o the
hand will create a much healthier appearance by decreasing the relative size and boniness o the joints.

787
Chapter 43 • Hand and Forearm Rejuvenation
M
a teri a l a n d M
eth od s
TECHNICAL GUIDELINES
Markings
Fig. 43-4
T e patient’s hands are marked; borders o placement are delineated by the orange line running along
the f ngers and down the ulnar and radial hand, crossing the proximal orearm. Areas where more tissue
will be placed are marked in green, and larger veins are marked in blue.

788
Part III • Clinical Applications • Upper Extremity
Anesthesia
Fig. 43-5
Heavy sedation and a double-level wrist block without local inf ltration are most o en used or anesthe-
sia o the hands, as was done or this patient. A solution o 1% lidocaine with 1:100,000 epinephrine is
placed superf cially with 25-gauge needles at two levels: one just proximal to the planned area o inf ltra-
tion and another approximately 2 cm proximal to the f rst block. A local anesthetic is placed at the sites
o planned incisions.
Incisions
Fig. 43-6
Incisions are a little longer than 1 mm; they are made with a No. 11 blade in the direction o the wrinkle
lines. Seven to nine incisions are spaced around the periphery and in the dorsum o the hand.
T e best locations or incision placement include the ollowing:
• In the dorsal hand
• At the little f nger MCP joint
• Web space between the ring f nger and middle f nger
• Radial index f nger
• Radial thumb
• Midwrist

789
Chapter 43 • Hand and Forearm Rejuvenation
Inf ltration Cannulas
Type I
Fig. 43-7
o avoid damage to underlying structures, particularly the veins, a blunt 1 -gauge cannula is used or
at placement in the hand. T is blunt inf ltration cannula is completely capped on the tip with a lip that
extends 1 0 degrees over a solitary distal aperture. I pre er cannulas that are or cm in length.
Level o Inf ltration
Fig. 43-8
T e level o placement is almost entirely in the immediate subdermal plane superf cial to the veins,
where it can provide support to the skin and thicken the skin.
Placement Volumes
I generally recommend placing at least 20 cc o at in each hand, and o en 0 cc or more. Additional at
will be required or patients desiring signif cant eathering onto the orearm or correction o intermeta-
carpal wasting. CAU ION: Overcorrection should be avoided unless specif cally requested by the patient.
I place only as much tissue as is needed to achieve a specif c result based on my previous experience.
TECHNIQUE
T e basic placement technique or the hands is similar to any location on the ace. However, the place-
ment is entirely superf cial with little i any layering. Generally, a similar pattern o placement with
anning rom a limited number o access points is ollowed in all hand cases. I inf ltrate over the f ngers,
entire dorsum o the hand, and f nally the dorsum o the wrist and orearm, i indicated. the gra ed at
is placed immediately subdermally. Slightly deeper placement may be needed or f lling deep intermeta-
carpal def ciencies.

790
Part III • Clinical Applications • Upper Extremity
A

B
Fig. 43-9, A and B
Using one central dorsal hand incision allows easier access to many areas on the dorsal hand. Fat is
placed f rst into the phalanges rom the middle o the dorsal hand to all o the f ngers and the thumb;
this di ers rom my previous practice o initial placement at the level o the MCP joints. T is allows eas-
ier access into the digits rom one central incision or access. Fat is transplanted over the dorsum o the
entire proximal phalanges. T e phalanges and web spaces o the f ngers and thumb are inf ltrated with
up to cc o at. Fat is placed up to the PIP and over the MCP joints. In this manner, the joints appear
smaller and better proportioned with the rest o the hand. T e transition rom the rest o the hand to the
joints is smooth. T is is ollowed immediately by placement over the MCP joints and web spaces.
C

D
Fig. 43-9, C and D
About 1 cc or more o at is placed into the f rst web space through the ulnar thumb incision and radial
index f nger incision. T e placement can proceed through these two incisions to the dorsal hand, all the
way to the palmar aspect.
E
Fig. 43-9, E
Fat is placed through the radial thumb incision to the radial dorsal hand in a radiating pattern, through
the f rst web space over the thumb metacarpal, and nearly to the palmar aspect o the radial hand. Ap-
proximately 3 cc or more is placed.

791
Chapter 43 • Hand and Forearm Rejuvenation
F

G
H

I
Fig. 43-9, F-I
Placement then proceeds rom an incision over the middle MCP joint and over the entire dorsum in a
proximal direction. T e radial hand incision at the MCP joint is used to place at over the dorsum to the
wrist, rom the juncture o the volar and dorsal sur aces. Fat is then placed in a radiating ashion through
the ulnar hand MCP incision o the little f nger. T e pattern extends almost to the ulnar aspect o the
palm and across the back o the hand. From the middorsal wrist incision, at is placed into the dorsum
o the hand and the wrist centrally.
Fig. 43-9, J
J
T rough the ulnar and then the wrist incision, a radiating pattern is placed, beginning at the palm and
extending across the dorsal hand and wrist to the distal radial orearm. Fat can be inf ltrated across the
wrist and distal orearm i needed to cover veins. T is area requires a surprising amount o at: at least
5 cc and as many as 0 cc may be needed. T e wrist needs a thicker layer than the rest o the hand or
orearm, because that is the primary site o wrinkling o the dorsal upper extremity. Incisions are usually
closed with Steri-Strips on the hands and nylon sutures on the body.

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Part III • Clinical Applications • Upper Extremity
Most Likely Technical Mistake
T e technical error most likely to occur is inadequate placement over the proximal digits. About 1 cc o
at should be gra ed into each proximal phalanx.
POSTOPERATIVE CARE
Fig. 43-10
T e hands, orearms, and proximal phalanges are dressed with Micro oam tape, which is le in place
or 3 or 4 days as a protective barrier. T e layer o tape on the skin o the inf ltrated areas creates a slight
compression over the gra ed areas that may reduce edema. T is tape also makes it di cult or the pa-
tient to touch the dorsal hand and inadvertently displace the newly placed atty tissue through the loose
areolar planes o the dorsal hand. Patients are instructed to avoid touching the backs o their hands or
at least 1 week, particularly during sleep, and also to avoid sleeping with their heads against their hands.
T ey are also told to keep their hands elevated above the level o the heart and to use cold compresses as
tolerated.

793
Chapter 43 • Hand and Forearm Rejuvenation
R esul ts
A
Preoperative
B
5 days postoperatively
C
12 days postoperatively
D
54 days postoperatively
E
7 years postoperatively
Fig. 43-11, A-E
T is 55-year-old woman thought that her hands looked much older than her face, and she complained
about the increasing visibility of her tendons and veins. She was not especially bothered by the wrin-
kling, but asked if something might be done about it. On physical examination, her tendons were more
visible than might be expected for her age, with the white color of the tendons clearly visible through the
thinning skin.

794
Part III • Clinical Applications • Upper Extremity
o treat her hands, at was harvested under epidural anesthesia in the ollowing quantities: 0 cc rom
the abdomen, 30 cc rom each medial thigh, and 15 cc rom each medial knee. T is 130 cc total was
ref ned down to 60 cc and divided equally between the two hands. T e ref ned at was placed over the
dorsum o the hand rom the middle hal o the proximal phalanx to the distal third o the orearm and
rom the ulnar palm to the radial palm. She had no intervening topical or surgical therapies to her hand.
Fig. 43-11, F-K
F

G
H
I
J
Preoperative
K
7 years postoperatively
On physical examination years later, she retained a subtle ullness over the proximal f ngers, dorsum o
the hand, and distal orearm. Her dorsal veins were barely visible and tendons were less def ned. She was
pleased that the one treatment had blunted her prominent veins and tendons, while giving her hands an
“elegant def nition.”

795
Chapter 43 • Hand and Forearm Rejuvenation
A

B

C
D

E

F
Preoperative
G
71⁄2 months postoperatively
H
19 months after second procedure
I
Fig. 43-12, A-I
T is -year-old woman presented complaining that her skin was thinning on the back o her hands,
with the tendons becoming more and more exposed. She was also bothered by the protuberance o her
MCP joints along with intermetacarpal wasting that gave her hands a bony appearance. She was espe-
cially concerned about having hands that looked too “ at,” because she had always had def ned hands.
She was also concerned about her rings not f tting properly.
I inf ltrated cc o at into the areas o the proximal phalanges o both hands and placed 6 cc into the
right dorsum and cc into the le dorsum. She was thrilled with the results 1⁄2 months a er her proce-
dure. However, because I limited the inf ltration o the proximal phalanges, the veins on her f ngers were
still visible. Also, the largest and most tortuous o the dorsal hand veins were still obvious. Her veins still
particularly bothered her when her hands were hanging down, causing the veins to f ll with blood.
She liked the appearance o her hands so much when they were swollen in the early postoperative period
that she returned asking or hands that were atter in appearance. T ere ore, 1 year a er the f rst proce-
dure, a second procedure was per ormed; cc o at was placed on the le and cc was placed on the
right digits. Into the dorsum 16 cc more was placed on both sides.

796
Part III • Clinical Applications • Upper Extremity
Fig. 43-12, J and K
J
Preoperative
K
19 months after second procedure
Nineteen months af er the second procedure, the patient’s dorsum almost completely obscured the veins
and tendons all the way to the PIP joint. Even though her hands appeared too ull or most people’s taste,
this patient loved the way her hands looked, even when she held them in a dependent position.
Fig. 43-13
Preoperative

2 years postoperatively
T is 54-year-old woman presented with translucent skin through which one could clearly see the blue
dorsal hand veins and glistening tendons. Fat removed rom her “love handles” was processed down into
usable tissue; 21 cc o at was placed into the lef hand and 25 cc into the right hand. She returned 2 years
later extremely pleased with the way her hands looked.

797
Chapter 43 • Hand and Forearm Rejuvenation
Fig. 43-14
Preoperative

39 months postoperatively
T is 62-year-old woman presented with crêpiness o her hand skin and increasingly noticeable veins and
tendons. She specif cally wanted to place a small amount o at onto the middle phalanx to decrease the
boniness o her PIP and MCP joints; 2 cc o ref ned at was placed into her le hand and 28 cc into her
right hand rom the distal orearm over the proximal phalanges and onto the middle phalanges almost
to the DIP joint. T e patient returned at months, enthusiastic about her results.

798
Part III • Clinical Applications • Upper Extremity
Fig. 43-15
Preoperative

1 year postoperatively
T is 52-year-old woman was bothered by the “bony look” o her hands with enlarged joints and prom-
inent tendons and veins. She had a history o arthritis that may have contributed to the enlarged joints;
she also had signif cant intermetacarpal wasting. All these actors combined to give her extremely
old-looking hands or a 52-year-old woman.