Operative Technique in Plastic Surgery – Kevin C.Chung

Maintain ratios of nipple in relation to the medial breast
border, lateral breast border, inframammary fold, and
superior breast extent.
T E C H N I Q U E S
■ C-V Flap
Flap Design
■ Generally, the desired diameter of the nipple is designed to be 1 cm.
■ The nipple is marked based on the above guidelines (see FIG 1) and is
confirmed by both the surgeon and the patient as being in an acceptable
position (TECH FIG 1).
■ The axis of the C-V flap is designed so that the mastectomy scar does NOT
cross either the C or V flaps.
■ The base of the nipple is marked to 1 cm in width and height.
■ The V flaps are then marked measuring 2.0 to 2.5 cm in length
■ The C flap is then marked 1 cm in width and 0.5 to 1 cm in height depending
on the skin laxity.
TECH FIG 1 • Design of C-V flap. A nipple with a base

of 1 cm and height of 1 cm is designed. The lateral V
flaps are marked measuring 2 to 2.5 cm in length, and
the C flap is designed with a height of 0.5 to 1 cm
depending on skin laxity.
Elevating and Insetting the Flap
■ The incisions are made to define the C and V flaps with care taken not to
transect the base of the flap or the attachment of the C flap to the vertical wall
(TECH FIG 2A).
■ The two V flaps are then elevated in a lateral to medial fashion with some
subcutaneous tissue (TECH FIG 2B).
■ Subcutaneous fat is included to improve nipple projection.
■ The C flap is the elevated to the base of the desired nipple with care to
maintain some fat at the base (TECH FIG 2C).
■ The donor site is then closed primarily in two layers with 3-0 Monocryl deep
dermal and running 5-0 Prolene suture (TECH FIG 2D).
■ The V flaps are then wrapped around the base overlapping and secured using
4-0 chromic sutures.
■ The C flap is then closed as the cap of the nipple (TECH FIG 2E).
■ A bolster-type dressing is created and placed, using two eye patches and an
adhesive dressing to avoid pressure on the nipple reconstruction.
TECH FIG 2 • Intraoperative incisions of C and V
flaps. A. Care made to not transect the base or the C
flap attachment to the vertical wall. B. V flaps elevated
in a lateral to medial fashion with subcutaneous
tissue. C. C flap is elevated to the base with care to
maintain fat along the base. D. Donor-site closure

primarily. E. V flaps are advanced and wrapped
around the base, and the C flap is closed over the top
of the V flaps as a cap.
PEARLS AND PITFALLS
Physical
findings
■ Nipple position on asymmetric breasts remains a great challenge.
■ Obtain breast symmetry PRIOR to nipple-areolar reconstruction.
■ Radiation proves challenging, and nipple reconstruction should be
undertaken only if there was resolution of acute radiation changes,
no evidence of late radiation changes, and appropriate thickness of
mastectomy skin flaps.11
Technique
■ Preoperative marking in the standing position with shoulders
relaxed is pivotal and the most important part of a successful
operation. If markings are made with shoulders abducted, the
nipple-areolar complex may be displaced superiorly and laterally,
and if made with the shoulders hunched, the nipple will be too
high postoperatively.
■ Preoperative markings must LOOK right. Proper appearance
should supplant measurements.
■ It is far better for nipple position to be low and lateral rather than
high or medial.
■ The axis of the C-V flap must be designed so that the mastectomy
scar does not cross the flaps.
■ Tension-free closure of donor site is imperative and prevents both
nipple flattening and distortion of breast mound.
Postoperative
■ Projection loss is estimated to be about 50%.
■ Dressing to avoid compression to the nipple reconstruction in the
early postoperative period is imperative.
Complications
■ Postoperative minor partial flap loss and delayed wound healing
problems are the most common.
■ Infection requiring implant removal is possible.

FIG 2 • A 55-year-old woman with a history of left breast
cancer underwent left mastectomy and tissue expander
reconstruction followed by implant exchange and right
breast mastopexy. Three months after mastopexy and
exchange, the patient had left nipple reconstruction with
C-V flap. A. Preoperative appearance. B. Postoperative
appearance after implant exchange and mastopexy. C.
Appearance 12 months after C-V flap reconstruction.
POSTOPERATIVE CARE
■ Patients routinely have occlusive dressings in place for 5 to 7 days
■ Avoid compression to the NAC, which can affect ultimate projection of the
nipple.
OUTCOMES
■ C-V flaps for nipple reconstruction provide good projection with minimal
complications in patients undergoing nipple reconstruction after mastectomy.
■ Overall decrease in projection is noted to be between 50% over time.4,5
■ Patients undergoing C-V flaps have good long-term results and patient
satisfaction (FIG 2).
COMPLICATIONS
■ C-V flap
■ Major complications are possible but very rare and include
• Complete necrosis of nipple
• Infection of the implant
• Implant extrusion
REFERENCES
1. Momoh AO, Colakoglu S, de Blacam C, et al. The impact of nipple

reconstruction on patient satisfaction in breast reconstruction. Ann Plast Surg.
2012;69(4):389-393.
2. Wellisch DK, Schain WS, Noone RB, Little JW III. The psychological
contribution of nipple addition in breast reconstruction. Plast Reconstr Surg.
1987;80(5):699-704.
3. Jones G, Bostwick J III. Nipple-areolar reconstruction. Operat Tech Plast
Reconstr Surg. 1994;1(1):35-38.
4. Losken A, Mackay GJ, Bostwick J III. Nipple reconstruction using the C-V
flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108(2):361-
369.
5. Valdatta L, Montemurro P, Tamborini F, et al. Our experience of nipple
reconstruction using the C-V flap technique: 1 year evaluation. J Plast
Reconstr Aesthet Surg. 2009;62(10):1293-1298.
6. Witt P, Dujon DG. The V-V flap—a simple modification of the C-V flap for
nipple reconstruction. J Plast Reconstr Aesthet Surg. 2013;66(7):1009-1010.
7. O’Neill JK, Goodwin-Walters A. Modifications to the C-V flap for nipple
reconstruction. J Plast Reconstr Aesthet Surg. 2010;63(4):e418-e419.
8. Macdonald CR, Nakhdjevani A, Shah A. The “Swiss-Roll” flap: a modified
C-V flap for nipple reconstruction. Breast. 2011; 20(5):475-477.
9. Temiz G, Yesiloglu N, Sirinoglu H, Sarici M. A new modification of C-V flap
technique in nipple reconstruction: rolled triangular dermal-fat flaps. Aesthetic
Plast Surg. 2015;39(1):173-175.
10. El-Ali K, Dalal M, Kat CC. Modified C-V flap for nipple reconstruction: our
results in 50 patients. J Plast Reconstr Aesthet Surg. 2009;62(8):991-996.
11. Draper LB, Bui DT, Chiu ES, et al. Nipple-areola reconstruction following
chest-wall irradiation for breast cancer: is it safe? Ann Plast Surg.
2005;55(1):12-15.

31
CHAPTER
Nipple Reconstruction
Kasandra Dassoulas, Brendan Collins, and Bernard W.
Chang
DEFINITION
■ Nipple reconstruction is the final stage in breast reconstruction and allows the
reconstructed breast to most closely resemble the natural breast.
■ There are many different techniques used to reconstruct the projecting portion
of the nipple-areolar complex; those reviewed in this chapter form the basis for
many other techniques.
ANATOMY
■ The nipple-areolar complex is an average of 4 cm in diameter, the nipple 1.3
cm in diameter, with the projecting portion 9 mm in length.1
■ The aesthetic ideal for the location of the NAC is at the apex, or most
projecting aspect of the breast mound.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Nipple reconstruction should be offered to appropriate candidates, generally as
the final step in the breast reconstruction process.
■ Nipple reconstruction is typically performed at least 3 months after either
autologous or final implant placement to allow incisions to completely heal and
the shape of the reconstruction to stabilize.
■ Presence and location of previous scars from breast reconstruction should be
noted.
■ The presence of a scar across the breast mound and its location may influence
the chosen reconstructive technique and decisions regarding placement.
■ Thickness of the skin and subcutaneous tissue as well as a history of radiation
should be noted.

■ In the case of implant-based reconstruction, if the soft tissue overlying an
implant is excessively thin or damaged from prior irradiation, nipple
reconstruction may carry a greater risk for skin necrosis, infection, and
implant exposure.
■ Under these circumstances, surgical nipple reconstruction should not be
offered or should be offered with caution. The patient may still be a candidate
for tattooing alone.
NONOPERATIVE MANAGEMENT
■ Tattooing without reconstruction of the projecting portion of the nipple is a
nonsurgical option.
SURGICAL MANAGEMENT
■ Once the decision has been made to pursue nipple reconstruction, the surgeon
must decide whether this will be combined with other revisionary procedures.
This may dictate the operative setting and anesthetic requirement, that is, office
vs outpatient surgery.
■ Nipple reconstruction alone can often be accomplished in the office with local
anesthesia.
Preoperative Planning
■ The location of the new nipple to be reconstructed is marked preoperatively
with the patient standing, oftentimes in front of a mirror to allow for patient
feedback.
■ Silicone nipples or telemetry pads can help illustrate the reconstructed nipple
location (FIG 1A,B).
Positioning
■ For unilateral reconstruction, the nipple position will reflect the contralateral
nipple position. If a contralateral symmetry procedure is needed, which will
change the position of the native nipple, that is, reduction or mastopexy, the
reconstructed nipple will reflect this new position.
■ The operation is performed with the patient in a supine position with arms
abducted 90 degrees or tucked at the patient’s sides. The patient should be
positioned with the option to elevate to a sitting position if desired.
Approach
■ Chosen technique may be based on nature and location of existing scars, as

well as surgeon preference. All techniques are associated with the tendency for
soft tissue contraction and decrease in nipple projection.
FIG 1 • A. Silicone nipples or telemetry pads can be
used to mark the site of the new nipple. B. The silicone
nipple can be traced to form the outside of the keyhole
pattern.
T E C H N I Q U E S
■ Star Flap
■ The star flap produces a moderately projecting nipple and minimal flattening
of the breast mound but does not offer projection of an areola or circular
border.
■ Three limbs are designed around a central portion (TECH FIG 1A). The
central portion base width determines the width of the nipple. The length of
the limbs of the star is based on the size of the contralateral nipple or a
width of 4 cm if there is no nipple present. The scars can be included in a
tattoo at a later point in time that will help to camouflage them.
■ The lateral wings of the flap are elevated sharply in a subdermal plane
(TECH FIG 1B).
■ The central wing of the flap is elevated distal to proximal including a
gradient of subcutaneous fat with the most at the central base, serving as
the bulk of the nipple (TECH FIG 1C).
■ One lateral wing is the wrapped centrally, followed by the other lateral

wing. Lastly, the central wing is closed over top. These are secured to each
other with interrupted percutaneous, nonabsorbable monofilament suture
(TECH FIG 1D).
■ The donor sites of the three wings are closed primarily (TECH FIG 1E).
TECH FIG 1 • A. Basic design of the start flap. B. The
lateral wings are elevated in a subdermal plane. C.
The central wing is elevated subdermally,
progressively recruiting subcutaneous tissue to add
bulk. D. The lateral wings are wrapped around the
central base. E. The central wing is closed over top.
The donor sites are closed primarily.
■ C-V Flap
■ Similar to the star flap, the C-V flap produces a moderately projecting
nipple, no areolar projection, and no circular scar.
■ The C-V flap is composed of two lateral limbs (V shaped) and central
component (C shaped). The lateral limbs are raised sharply in a subdermal
plane (TECH FIG 2A).
■ The central C-shaped portion is raised with subcutaneous tissue included to

add bulk to the nipple (TECH FIG 2B).
■ Each V-shaped lateral limb is then brought centrally and secured together,
end to end or overlapping for greater nipple projection (TECH FIG 2C).
■ The C-shaped central component is brought over the top of the
reconstructed nipple and secured to form the nipple (TECH FIG 2D).
■ The donor sites are closed primarily.
TECH FIG 2 • A. Lateral limbs are elevated
subdermally. B. The central C-shaped portion is
elevated, including a layer of subcutaneous tissue. C.
Lateral limbs are wrapped centrally. D. The C limb is
closed over top of the lateral limbs and donor sites
closed primarily.
■ Keyhole Flap
■ The keyhole flap produces a moderately projecting nipple and areola. It

lends well to reconstruction on circular skin paddles of autologous
reconstructions.
■ The nipple is based on a central wedge, which is shaped like a keyhole,
surrounded by a semicircularly incised skin flap (TECH FIG 3A).
■ The keyhole and the border of the nipple are incised sharply. The keyhole
is raised with some subcutaneous fat along the dermis (TECH FIG 3B,C).
■ The keyhole is folded upon itself to create the projecting portion of the
nipple (TECH FIG 3D).
■ The remaining circular portion of the flap is advanced to fill the donor site,
which is then closed primarily (TECH FIG 3E–G).
■ The keyhole flap (or any of the techniques described in this chapter) can be
combined with a tattoo after healing. Tattoo combined with keyhole flap is
shown in TECH FIG 3H.

TECH FIG 3 • A. Basic design of the keyhole flap. B.
The incisions are made sharply. C. The central portion
is elevated, progressively recruiting subcutaneous
tissue. D. The central portion is folded on itself and
secured with 5-0 nylon. E. The apex of the remaining
inner circular edge is secured as a tristitch with the
central portion. F. The apex of the outer circular edge
is secured with a tristitch. G. The donor site is closed
with interrupted deep dermal 5-0 Vicryl suture followed
by running 5-0 nylon. H. Postoperative result of
bilateral nipple reconstructions using the keyhole
technique, followed by tattoo.
■ Nipple-Sharing Technique
■ Patients with contralateral nipples greater than 5 to 6 mm may be candidates
for this technique.
■ The location of the new nipple on the reconstructed breast is marked and
de-epithelialized.
■ Then, a traction suture is placed through the distal end of the contralateral
nipple, which is then placed on stretch. The distal 50% of it is removed
sharply with a scalpel.
■ The transected nipple is secured to the de-epithelialized recipient site with
chromic sutures and dressed with a bolster, or a nipple protector is used to
secure it.
■ The donor site is closed with either a purse-string or interrupted sutures.
■ Reconstruction of the areola may be accomplished with tattoo or skin graft
from distant donor sites including excess skin from the abdomen or
superomedial thigh.
■ Autologous, Allograft, and Alloplastic Materials
■ A variety of autologous, allograft, and alloplastic materials have been
described to augment and sustain projection of the nipple, including cartilage,
acellular dermal matrix, silicone, hyaluronic acid, and prosthetic devices.

■ The chosen material must be manipulated into an acceptable size and shape
to serve as a nipple.
■ Materials can be combined with a C-V flap, placing them under the C-
shaped central portion of the flap. The lateral V-shaped limbs of the flap are
wrapped around the material and secured with permanent suture.
■ Alternatively, a semicircular pocket can be dissected, the material placed
within the pocket, and the skin closed over top. This can then be combined
with a tattoo for pigment after healing has been completed (TECH FIG 4).
TECH FIG 4 • Postoperative results after left breast
subdermal cartilage allograft placement, followed by
tattoo.
PEARLS AND PITFALLS
Patient
selection
■ Candidates with implants must have healthy skin of sufficient
thickness to avoid major complications such as implant exposure.
Timing
■ Nipple reconstruction should be performed as the final procedure,
ideally after results of other symmetry procedures and revisions have
had time to stabilize, at least 3 months.
Technique
selection
■ Star and C-V flaps work well for implant-based reconstructions.
■ The keyhole flap is ideal for autologous reconstruction with a round
skin paddle and can also be used for implant-based reconstruction with
a semicircular outer incision.

■ Consider nipple share for patients with excessive contralateral nipple
length.
■ Use of foreign materials can be helpful with maintaining projection;
however, patients should be counseled preoperatively that the
projection is maintained continuously, unlike a native nipple with
erectile function.
Outcomes
■ Patients should always be cautioned preoperatively that some degree
of loss of projection is expected.
■ Always consider flap design relative to existing incisions, as this will
impact blood supply.
POSTOPERATIVE CARE
■ The reconstructed nipple is protected with a formal nipple shield or gauze with
a central portion removed to accommodate the projecting nipple.
■ In cases of nipple share and skin grafting to the areola, the bolster may be left
for 5 to 7 days, similar to a full-thickness skin graft.
OUTCOMES
■ The star flap is associated with a 43% loss in nipple projection at 12 months.2
■ The C-V flap has been shown to have a 32% loss of projection at 12 months.3
■ Nipple-sharing technique can be associated with some decrease in sensation of
the donor site. This was a subjective finding in 47% of patients who underwent
this technique.4
COMPLICATIONS
■ Virtually all techniques are associated with loss of projection to some degree.
■ Infection, asymmetry, malposition, graft loss, and wound separation are other
potential complications.
■ Nipple reconstruction performed over thin, compromised skin can lead to
wound healing problems resulting in implant exposure.
■ Using foreign devices for nipple augmentation may be complicated by
exposure or extrusion, necessitating removal of the device.
REFERENCES
1. Sanuki J, Fukuma E, Uchida Y. Morphologic study of nipple-areola complex
in 600 breasts. Aesthetic Plast Surg. 2009;33(3):295-297.
2. Shestak KC, Gabriel A, Landecker A, et al. Assessment of long-term nipple
projection: a comparison of three techniques. Plast Reconstr Surg.

2002;110(3):780-786.
3. Valdatta L, Montemurro P, Tamborini F, et al. Our experience of nipple
reconstruction using the C-V flap technique: 1 year evaluation. J Plast
Reconstr Aesthet Surg. 2009;62(10):1293-1298.
4. Edsander-Nord A, Wickman M, Hansson P. Threshold of tactile perception
after nipple-sharing: a prospective study. Scand J Plast Reconstr Surg Hand
Surg. 2002;36(4):216-220.

32
CHAPTER
Low-Volume Fat Grafting for
Contour Correction
Nolan Karp and Jordan Frey
DEFINITION
■ The popularity of fat grafting to the breast has grown immensely since it was
first described in the late 19th century with greater than 60% of plastic
surgeons now utilizing fat grafting in reconstructive breast surgery.1,2
■ Autologous fat grafting has proven to be extremely efficacious in correcting
volume and contour deformities both after postmastectomy breast
reconstruction and after breast-conserving therapy.1,3–5
■ However, autologous fat grafting is most commonly employed in
postmastectomy breast reconstruction as an adjunctive procedure after implant-
or flap-based reconstruction.1,4,5
ANATOMY
■ Contour deformities of the breast to be corrected with small-volume fat
grafting may arise from a myriad of anatomical etiologies.
■ In implant-based breast reconstruction, the gentle slope of the natural superior
chest wall–breast junction is often difficult to reconstruct, resulting in a
superior shelf contour deformity.
■ Additional volume or contour abnormalities to be corrected may arise from
size discrepancy between the implant and breast envelope or inadequate
implant volume or due to complications of the initial reconstruction, such as
mastectomy flap necrosis.6
■ In autologous breast reconstruction, irregularities requiring fat grafting may
develop due to inadequately sized flaps secondary to donor site paucity as well
as from flap complications, such as fat necrosis.6
■ Patients with small breasts or large tumors are particularly prone to contour

irregularities that require fat grafting after breast-conserving therapy.3
■ Possible anatomical donor sites for small-volume fat grafting of the breast
include the abdomen, flanks, lateral and medial thighs, back, and buttocks.5
■ Adipocyte viability does not appear to differ based on the donor site from
which it is harvested.1,7,8
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The decision to proceed with fat grafting to the breast for contour correction
after either breast reconstruction or breast-conserving therapy is based largely
on physical examination and patient preference.
■ Patients should be followed at regular intervals after their initial breast
reconstruction to evaluate for evolving breast volume asymmetries or contour
irregularities.
■ In evaluating a subpectoral implant reconstruction, the breasts should be
examined both statically and with pectoral contraction to observe for dynamic
irregularities.
■ Patient expectations should be assessed prior to proceeding with fat grafting;
patients should be made aware of any prereconstruction breast asymmetries
that will not be changed by fat grafting.
■ Donor sites are chosen based on availability and patient preference to ensure
that there is sufficient autologous fat to correct all breast deformities.8
IMAGING
■ Patient photography should be obtained after breast reconstruction and
compared with preoperative photographs to help plan for contour correction
with fat grafting.
■ Traditional radiographic imaging is typically not required prior to secondary
breast reconstruction with small-volume fat grafting.
■ MRI may at times be helpful in assessing the volume required for adequate
contour correction; there is a substantial added cost with this technology,
however.
■ 3D imaging has recently been employed to assist with preoperative
identification and quantification of breast volume deficiencies and
asymmetries.9,10
SURGICAL MANAGEMENT
■ Patients should wait a minimum of 3 to 4 months after their final implant

placement, flap reconstruction, or breast-conserving procedure prior to
proceeding with fat grafting for contour correction.
■ This will allow adequate time for tissues to heal and soften, both defining the
final contour of the breast and increasing recipient bed vascularity.
■ In general, small-volume fat grafting of the breast is best accomplished under
general anesthesia given the multiple areas of surgery and need for position
changes.
Preoperative Planning
■ Physical examination, patient photography, and 3D imaging should be utilized
preoperatively to precisely plan the location and amount of fat grafting required
for adequate contour correction.9,10
■ Given the fluctuating nature of adipose deposits, potential donor sites should
be reassessed on the day of surgery to plan the volume of autologous fat to be
harvested from each site.
Positioning
■ Patient positioning in the operating room is dependent on the donor sites from
which autologous fat will be obtained.
■ Patients should be positioned on a bed permitting flexion at the hips so that the
patient may be able to “sit up” during the procedure.
■ A prone position with arms extended forward in a diver’s pose is necessary if
the back or buttocks are to be harvested.
■ If required, the patient should begin in the prone position for autologous fat
harvest prior to being placed in the supine position for additional fat harvest
and recipient site grafting as indicated.
■ A supine position is planned if the abdominal, flank, or lateral and medial
thigh donor sites are to be harvested.
■ These sites are advantageous as both donor site harvesting and recipient site
fat injection can proceed without position change.
■ In the supine position, the arms should be abducted at approximately 90
degrees and secured to the arm boards in preparation for sitting the patient up
during the procedure.
Approach
■ The donor site areas from which the autologous fat will be harvested should be

marked with concentric circles. Recipient site areas into which the fat will be
grafted should be marked with cross-hatches on the patient.
■ Markings for cannula access incisions should be placed in all donor and
recipient sites within relaxed skin tension lines in areas typically hidden by
clothing.
T E C H N I Q U E S
■ Tumescent Infiltration of Donor and Recipient
Sites
■ Tumescent solution is prepared using 20 cc of 2% lidocaine, 1 mg of 1:1000
epinephrine within one liter of lactated Ringer solution.8
■ Lidocaine concentrations of 35 mg/kg have been proven safe using the
tumescent technique.11
■ Planned 2-mm stab incisions near donor and recipient sites are made with an
11-blade while pinching the skin to avoid damage to deeper structures.
■ Tumescent solution is infiltrated using a tumescent cannula at rates ranging
from 50 to 200 mL/min into all areas of autologous fat harvest as well as all
planned recipient sites.11
■ The end point of tumescent infiltration is judged on the basis of tissue turgor
and skin blanching and is generally in the ratio of 2:1 infiltrate to aspirate.11
■ Ideally, 15 to 20 minutes is allowed to elapse prior to liposuction fat
harvesting to maximize the vasoconstrictive effect of the tumescent
solution.12
■ Donor Site Autologous Fat Harvesting With
Liposuction
■ Given ease and efficacy of use, suction-assisted liposuction is the senior
author’s preferred method of donor site autologous fat harvesting.
■ Adipocyte viability with handheld and suction-assisted liposuction is
equivalent when utilized with tumescent solution infiltration.8
■ Generally, 3 to 4 mm cannulas are preferred as greater cannula size has been

associated with improved adipocyte viability.8
■ Multiperforated or two-hole Coleman cannulas may be employed with
similar outcomes.8,13
■ Cannula length is chosen based on the reach required for each given donor
site.
■ Fat is harvested from the deep layer of subcutaneous fat, taking care to avoid
the subdermal and superficial fat layers (TECH FIG 1A).
■ Liposuction of the subdermal or superficial fat layers can result in visible
and unattractive skin dimpling.
■ Within each donor site area, tissue is rolled between the thumb and index
finger of the nondominant hand, while the liposuction cannula makes broad
passes between the digits (TECH FIG 1B).
■ After each 2 to 3 passes of the cannula in one area, the cannula is reoriented
to an adjacent region to avoid overliposuction in any discrete area, which will
result in donor site depressions and asymmetries (TECH FIG 1C).
■ In the abdomen, posterior direction of the liposuction cannula risks
perforation of the peritoneal cavity with concomitant intra-abdominal injury.
■ Caution must also be exercised in the epigastric and subcostal abdominal
regions where inattentive technique can risk violation of the thoracic cavity.
■ Fat harvesting proceeds until sufficient fat to correct all breast irregularities
(estimated preoperatively) is obtained or all planned donor sites are depleted
of useable autologous fat without the creation of donor site deformity.

TECH FIG 1 • A. Cross-sectional anatomy of the skin
and subcutaneous fat. Liposuction fat harvesting for
small-volume fat grafting of the breast should be
performed in the deep subcutaneous fat layer while
the subdermal and superficial fat layers are avoided to
prevent donor site contour abnormalities such as
dimpling. B. Technique for donor site autologous fat
harvesting. The donor site tissue (abdominal tissue in
this figure) is rolled between the thumb and index
finger of the nondominant hand while the liposuction
cannula makes broad passes between the digits. This
provides the surgeon with tactile manual feedback that

will assist with maintaining the cannula in the
appropriate fat plane. C. “Fanning” technique for
donor site liposuction. After each 2 to 3 passes of the
liposuction cannula in one area, adjacent tissue is
taken up in a fanning pattern to avoid overliposuction
in any one area.
■ Fat Aspirate Processing
■ Autologous fat aspirate, once harvested, must be processed to separate the
fat, stromal vascular fraction cells, and adipose-derived stem cells from
tumescent solution and blood.8
■ Fat aspirate may be processed by centrifugation, gravity separation, washing,
and/or filtration.8
■ Although animal studies suggest that centrifugation with filtration provides
smaller fat grafts with impaired integrity, in vivo patient studies show no
difference in fat graft retention based on different processing techniques.8
■ Centrifugation forces greater than 50 g after suction-assisted liposuction
have been shown to result in significant adipocyte damage; this effect is not
observed after handheld liposuction.8
■ After centrifugation, the lowest layer of the fat aspirate contains the most
viable adipocytes for injection while higher layers progressively contain less
viable cells.8
■ The senior author currently prefers a combined hand washing-filtration
system for autologous fat processing prior to small-volume fat grafting of the
breast.
■ Recipient Site Fat Grafting (Video)
■ Filtered fat is separated into 3- or 6-mL syringes and attached to the chosen
cannula.
■ Injection cannulas are generally smaller in diameter than harvesting cannulas
and only have a single distal or lateral port for fat egress.13
■ The cannula size utilized will depend on the body area to be grafted with 16-
or 17-gauge cannulas most often employed for small-volume fat grafting of

the breast.13
■ The length, shape, and curve of the cannula chosen are based on the
geometry of the recipient site and location of recipient site access incisions.13
■ The cannula is inserted into the access incision and guided into the area to be
grafted; fat is slowly injected as the cannula is withdrawn8,13 (TECH FIG
2A).
■ Approximately 1-2 mL is injected with each pass of the cannula.13
■ Scar contracture release may be performed through multiple punctures with
the beveled tip of an 18-gauge needle to prevent dimpling and undue tension
at the site of fat injection14 (TECH FIG 2B).
■ After implant-based breast reconstruction, processed fat may be injected into
both the subcutaneous fat and muscle planes as indicated to correct any
contour deformities (TECH FIG 2C).

TECH FIG 2 • A. Harvested and processed fat is
slowly injected into any recipient site contour
deformities through the access incision as the cannula
is withdrawn. In this figure, the recipient site access
incision is hidden in the anterior axillary line. B. Scar
contracture release is often performed prior to fat

injection through multiple punctures with the beveled
tip of an 18-gauge needle to prevent dimpling and
undue tension at the site of injection. This is especially
useful after breast-conserving therapy in order to
create sufficient space for the fat to be grafted. C.
After implant-based breast reconstruction, fat may be
injected into both the subcutaneous fat and muscle
layers as indicated to correct any contour deformities
present. The decreased fat retention typically
observed with injection into contractile muscle is
obviated after breast reconstruction due to pectoralis
disinsertion. Care must be taken to avoid trauma to
the implant itself from the cannula that can result in
rupture.
■ In autologous breast reconstruction, fat may be injected into the
subcutaneous fat plane or into the flap itself; care must be taken to protect
the vascular pedicle if deeper fat injection is planned.
■ After breast-conserving therapy, fat is typically injected into the glandular
breast tissue and less often into the subcutaneous fat plane.
■ Scar contracture release is usually required to create space for the fat in this
circumstance.
■ Slower injection speeds result in larger fat deposits; however, faster injection
speeds increase the risk of adipocyte cellular injury.8
■ Each planned recipient site is sequentially injected to the desired final effect
and contour correction.
■ Wound Closure
■ Donor site harvest and recipient site access incisions are closed with simple
interrupted fast-absorbing sutures and dressed with adhesive bandage strips
and semiocclusive dressings.

PEARLS AND PITFALLS
Preoperative
planning
■ 3D imaging may be utilized preoperatively to analyze predicted
volume requirements in the breast and aid in patient
education.9,10
Donor and
recipient site
access incision
placement
■ Recipient site access incisions for the breast can be hidden in the
anterior axillary line, the medial and lateral breast folds, and the
inframammary fold.
■ Avoid access incisions in the upper medial breast, abdomen or
flanks above the bikini line, and lateral or medial thighs below
the bikini line.
■ Particular care must be taken when donor site stab incisions are
made in the groin; the femoral artery should be palpated with
incisions made laterally to avoid both the femoral artery and
more medial femoral vein.
Tissue planes
of fat injection
■ Care should be taken to avoid overly superficial or subdermal
injections that will result in unaesthetic visible and palpable
deformities.
Initial fat
injection
■ Care is taken to achieve optimal placement during initial fat
transfer.
■ Alteration of any undesired fat accumulations is difficult to
achieve with massage or manual manipulation and may require
liposuction of the abnormal area.13
Intraoperative
assessment of
contour
correction
■ The patient should be periodically sat up by flexing the
operative bed during fat injection to assess breast volume and
symmetry in both the supine and upright position.
■ Fat may even be injected with the patient in the upright, seated
position.
Complications
■ Although not reported, intravascular fat injection resulting in
devastating fat embolism with small-volume fat grafting to the
breast is a theoretical risk of the procedure.
■ Utilizing blunt tip injection cannulas and injecting only during
cannula withdrawal will minimize the risk of intravascular
injection.
POSTOPERATIVE CARE
■ Generally well tolerated, patients usually are discharged on the same day as
their small-volume breast fat grafting procedure.

■ Oral antibiotics with skin flora coverage should be provided for up to seven
days; this is especially important in cases of secondary fat grafting after
implant-based breast reconstruction to avoid prosthesis-related infections.
■ Surgical bras may be provided to patients with instructions to avoid underwire
bras or pressure on the areas in which fat was injected for at least 6 weeks.
■ Compressive garments may also be worn over the abdominal, flank, back, or
thigh donor sites according to patient and/or physician preference.
■ Patients should be advised to expect some leakage of fluid from access
incisions for 1 to 2 days and bruising of the donor site for the first 2 to 3 weeks
postoperatively.15
OUTCOMES
■ Secondary small-volume fat grafting as an adjunct to breast reconstruction and
breast-conserving therapy has been shown to significantly improve aesthetic
breast contour and volume.3,15,16
■ Patient satisfaction after secondary small-volume fat grafting to the breast
appears high.4
■ The amount of fat retained long term after small-volume fat grafting to the
breast ranges from near 40% to 50%.1
■ Larger volumes of fat grafting appears to have increased retention, whereas the
donor site likely has no significant influence on fat retention.5
■ Abnormalities found on surveillance radiographic breast imaging after fat
grafting are acceptably low and less than those seen after reduction
mammoplasty.17
■ Despite concern, the risk of locoregional breast cancer recurrence does not
appear to be increased after secondary small-volume fat grafting to the
breast.18
COMPLICATIONS
■ Donor site issues, most frequently irregularities and depressions, represent the
most common complications after this procedure.15,19
■ Other donor site issues, such as hematoma and seroma formation, are less
prevalent.15,19
■ Donor or recipient site infection after small-volume fat grafting to the breast is
rare, generally less than 1%.4,15,19
■ Implant rupture, if fat grafting is performed after prosthetic breast

reconstruction, is likewise rare but may occur due to cannula trauma.
■ Fat necrosis and oil cysts may develop after small-volume fat grafting of the
breast, more commonly if fat is injected in larger aliquots within the same
tissue plane.
■ Significant blood loss with this procedure is very rare, especially with the use
of tumescent solution during which blood loss approximates 1% of the total
fluid aspirated.11
REFERENCES
1. Choi M, Small K, Levovitz C, et al. The volumetric analysis of fat graft
survival in breast reconstruction. Plast Reconstr Surg. 2013;131(2):185-191.
2. Kling RE, Mehrara BJ, Pusic AL, et al. Trends in autologous fat grafting to
the breast: a national survey of the American society of plastic surgeons. Plast
Reconstr Surg. 2013;132(1):35-46.
3. Biazus JV, Falcão CC, Parizotto AC, et al. Immediate reconstruction with
autologous fat transfer following breast-conserving surgery. Breast J.
2015;21(3):268-275.
4. Kaoutzanis C, Xin M, Ballard TN, et al. Autologous fat grafting after breast
reconstruction in postmastectomy patients: complications, biopsy rates, and
locoregional cancer recurrence rates. Ann Plast Surg. 2016;76(3):270-275.
5. Small K, Choi M, Petruolo O, et al. Is there an ideal donor site of fat for
secondary breast reconstruction? Aesthet Surg J. 2014;34(4):545-550.
6. Weichman KE, Broer PN, Tanna N, et al. The role of autologous fat grafting
in secondary microsurgical breast reconstruction. Ann Plast Surg.
2013;71(1):24-30.
7. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat transfer
viability: a quantitative analysis of the role of centrifugation and harvest site.
Plast Reconstr Surg. 2004;113(1):391-395.
8. Strong AL, Cederna PS, Rubin JP, et al. The current state of fat grafting: a
review of harvesting, processing, and injection techniques. Plast Reconstr
Surg. 2015;136(4):897-912.
9. Patete P, Rigotti G, Marchi A, Baroni G. Computer assisted planning of
autologous fat grafting in breast. Comput Aided Surg. 2013;18(1–2):10-18.
10. Tepper OM, Unger JG, Small KH, et al. Mammometrics: the standardization
of aesthetic and reconstructive breast surgery. Plast Reconstr Surg.
2010;125(1):393-400.
11. Klein JA. Tumescent technique for local anesthesia improves safety in large-

volume liposuction. Plast Reconstr Surg. 1993;92(6):1085-1098.
12. Mckee DE, Lalonde DH, Thoma A, Dickson L. Achieving the optimal
epinephrine effect in wide awake hand surgery using local anesthesia without a
tourniquet. Hand (N Y). 2015;10(4):613-615.
13. Coleman SR. Structural fat grafting: more than a permanent filler. Plast
Reconstr Surg. 2006;118(3 suppl):108S-120S.
14. Khouri RK, Smit JM, Cardoso E, et al. Percutaneous aponeurotomy and
lipofilling: a regenerative alternative to flap reconstruction? Plast Reconstr
Surg. 2013;132(5):1280-1290.
15. Illouz YG, Sterodimas A. Autologous fat transplantation to the breast: a
personal technique with 25 years of experience. Aesthetic Plast Surg.
2009;33(5):706-715.
16. de Blacam C, Momoh AO, Colakoglu S, et al. Evaluation of clinical
outcomes and aesthetic results after autologous fat grafting for contour
deformities of the reconstructed breast. Plast Reconstr Surg.
2011;128(5):411e-418e.
17. Rubin JP, Coon D, Zuley M, et al. Mammographic changes after fat transfer
to the breast compared with changes after breast reduction: a blinded study.
Plast Reconstr Surg. 2012;129(5):1029-1038.
18. Kronowitz SJ, Mandujano CC, Liu J, et al. Lipofilling of the breast does not
increase the risk of recurrence of breast cancer: a matched controlled study.
Plast Reconstr Surg. 2016;137(2):385-393.
19. Maione L, Vinci V, Klinger M, et al. Autologous fat graft by needle: analysis
of complications after 1000 patients. Ann Plast Surg. 2015;74(3):277-280.

33
CHAPTER
Large-Volume Fat Grafting
for the Breast
Wesley N. Sivak and J. Peter Rubin
DEFINITION
■ Autologous fat grafting has become a common technique for addressing
volume and contour deficiencies in plastic surgery.
■ A survey conducted in 2013 showed that approximately 80% of plastic
surgeons have incorporated fat grafting into their clinical breast surgery
practice.1
■ Fat grafting has been utilized for facial rejuvenation, breast augmentation,
mitigating radiation damage, capsular contracture, post-traumatic
deformities, congenital anomalies, and burn injuries.
■ Autologous fat grafts have numerous beneficial characteristics including
simple surgical procedure, low cost, and nearly universal accessibility.
■ Although early use was largely as an aesthetic treatment, recent advancements
have made fat grafting an attractive alternative for many reconstructive
challenges.
■ Contour abnormalities and volume defects of the breast routinely require
large-volume fat grafting, often necessitating several sessions to achieve the
desired result.
ANATOMY
■ Female breasts are composed of glandular tissue that produces milk and
adipose tissue; the amount and distribution of fat largely determine the size and
shape.
■ Milk production within the breast occurs within lobules that are organized into
15 to 20 lobes. Milk travels through a network of ducts that coalesce and exit
the skin via the nipple.

■ Adipose tissue, connective tissue, and ligaments provide support and shape to
the breast. Nerves passing through these tissues provide sensation. The breast
contains abundant blood vessels, lymph vessels, and lymph nodes.
■ The breast due to its architecture and rich blood supply responds well to fat
transfer; the architecture permits expansion of the tissues while ensuring close
proximity to blood supply.
■ Fat grafts are typically harvested from a donor region of abundance (eg,
abdomen, flank, or thigh) and serially injected into the deficient recipient site.
■ Harvested adipose tissue is composed of particles of tissue encompassing
adipocytes and stromal vascular fraction cells, which include adipose stem
cells (ASCs) or preadipocytes, fibroblasts, vascular endothelial cells, and a
variety of immune cells.
■ Clinical studies have demonstrated safety and favorable fat graft retention
rates with strict adherence to basic principles and proper, rigorous technique
(ie, Coleman technique).
■ Stromal vascular fraction cells (and the ASCs within) improve fat graft
survival, largely through their angiogenic properties.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patient selection must begin with a detailed history, noting pertinent medical
comorbidities that may limit therapeutic potential.
■ Candidates must be able to withstand the anesthetic requirements of the
procedure; it may not be prudent to offer fat grafting to those with significant
systemic ailments.
■ Fat grafting to small areas can be performed under local anesthesia, but
large-volume grafting will generally require sedation at a minimum.
■ Physical examination entails a thorough assessment of the defect in question in
addition to assessment of potential donor sites.
■ This allows the physician to formulate a plan for correction of the defect in
question.
■ Patients must be informed that several rounds of fat grafting may be needed
to achieve the desired results.
■ For fat grafting to the breasts, significant fat volume is generally required;
often, there is a limit as to the correction that can be made given the paucity of
fat in some patients.
■ Asking the patient to gain weight prior to the procedure is feasible only if the
patient is willing and able to maintain that weight afterward. This strategy is

generally not recommended as weight loss following fat grafting can lead to
loss of volume and failure to maintain adequate correction.
IMAGING
■ For breast fat grafting, screening mammography should be performed
preoperatively consistent with current guidelines.
■ Typically, no radiologic or other diagnostic studies are required; physical
examination alone will suffice to formulate an effective grafting strategy.
SURGICAL MANAGEMENT
■ It is not sufficient to merely graft fat diffusely in the breast. The grafted fat
must be placed appropriately to accomplish the desired objectives of shaping
the breast.
■ The surgeon must be familiar with the potential levels of placement (eg,
subdermal, subglandular, intramuscular, and supraperiosteal) and the amounts
necessary at each level to accomplish a desirable change.
■ These amounts will vary across regions of the body as well as from patient to
patient.
■ Determining the amounts of fat to place and the levels in which to place the
fat in order to create subtle, lasting contour changes requires a sophisticated
surgical plan.
■ The Coleman method of fat grafting remains essentially unchanged since the
original inception three decades ago.2
■ The process relies upon harvesting the fat gently to preserve its architecture,
refining the fat with centrifugation to remove nonviable components and
provide a predictable volume, and placement of the fat in small aliquots to
increase the surface area and ensure a robust blood supply to the grafted
tissue.
■ When these principles are adhered to, fat grafting can be a reproducible and
safe procedure.
■ Histologic studies have shown that this method of harvesting and refinement
with centrifugation yields fat with a high percentage of survival and near-
normal adipose cellular enzyme activity.3
■ However, this method of fat processing lacks efficiency for large-volume fat
grafting. Therefore, the Coleman technique is used to refine results of large-
volume fat grafting (“touch-up” procedures), and a simple method of
harvesting large volumes of fat with machine-powered suction and decanting

the aspirate is described below.
Preoperative Planning
■ Patients should be marked in the standing position prior to surgery. When in
the operating room, significant changes in breast shape can occur with changes
in position.
■ Areas of volume deficiency on the breast should be marked and the volume to
be added estimated, keeping in mind that approximately 40% resorption of
volume can be expected during healing. The plane of injection will depend on
surgical goals. Superior pole fullness can be achieved predominantly with
subcutaneous injection, whereas increasing central projection will require deep
injection.
■ A mastopexy can be performed concurrent with fat grafting, and we
recommend a technique with minimal parenchymal dissection to preserve
nipple/areolar blood supply after grafting.
■ Concentric circles should be drawn around adipose depots that are going to be
harvested to ensure areas are not overharvested.
Positioning
■ With the patient in the supine position, both typical donor sites (eg, abdomen,
flank, and thigh) and the breasts are easily accessible.
■ Following fat harvest and processing, grafting can be done with the patient
either supine or with the bed flexed into a sitting position with arms abducted.
■ Sitting position will allow for better assessment and correction of ptosis,
clearly delineating the inframammary fold.
■ Supine position will make it more difficult to judge changes in shape during
the fat injection.
Approach
■ For large-volume fat injection, the principles of harvest and injection must be
adapted to enable greater volumes of fat to be handled efficiently in the
operating room.
T E C H N I Q U E S

■ Fat Harvest
■ Access incisions should be hidden in skin creases, scars, stretch marks, or
hair-bearing areas, if at all possible.
■ For large-volume harvest, local anesthetic solution is then infiltrated using a
blunt infiltration cannula.
■ Local anesthetic mixture consists of 0.025% lidocaine with 1:1 000 000
epinephrine and is a standard wetting solution used for liposuction.
■ The amount of solution infiltrated is equal to the amount of fat removed
(1:1 ratio, superwet technique).
■ After waiting approximately 10 minutes for the local anesthetic solution to
take effect, fat is then harvested using a 3-mm harvesting cannula.
■ The cannula may be utilized with any vacuum- or power-assisted liposuction
equipment or simply attached to a syringe.
■ For small-volume harvest, local anesthetic solution is then infiltrated using a
blunt infiltration cannula.
■ Local anesthetic mixture consists of 0.1% lidocaine with 1:200 000
epinephrine and is a higher concentration of epinephrine than a standard
wetting solution used for liposuction.
■ The amount of solution infiltrated is equal to approximately 25% of the
amount of fat removed (injected sparingly).
■ After waiting approximately 10 minutes for the local anesthetic solution to
take effect, fat is harvested using a Coleman bucket handled harvesting
cannula attached to a 10-cc syringe barrel.
■ Following harvest, incisions are closed with interrupted 5-0 fast-absorbing
sutures.
■ Fat Processing
■ For small-volume Coleman technique, a Luer-Lok plug is used to cap the
syringe.
■ The plunger is removed, and the syringe is placed into a sterile centrifuge.
■ Centrifugation at 3000 rpm (1200 g) for 3 minutes concentrates the fat so
that the aqueous components (ie, local anesthetic and blood) can be removed
and discarded by releasing the Luer-Lok plug.
■ Any oil layer can be decanted off the top and/or wicked away with gauze

pads.
■ The processed fat is then ready for injection.
■ For larger volumes, simple decantation from a large reservoir can be utilized
in lieu of centrifugation (TECH FIG 1). Fat is collected into a sterile canister
and allowed to decant for 5 to 10 minutes. Aqueous fluid is aspirated and the
fat poured into 30-cc syringe barrels.
TECH FIG 1 • A. Large-volume fat harvest and
processing represent a logistical challenge in the
operating room. A simple apparatus consists of a
sterile collection chamber set up in-line on the sterile
field. Machine-generated suction from a standard
liposuction aspirator is applied through the system,
and a standard liposuction cannula of 3- or 4-mm
diameter is used to harvest fat into the vessel. B,C.
The aspirate is allowed to decant until the fat
separates from the aqueous layer. The aqueous layer
is then removed by aspiration with a suction cannula.
Commercially available vessels for large-volume fat
collection are also constructed with spigots at the
base to drain the aqueous layer. (Reproduced from
Sivak WN, Rubin JP. Repair and grafting fat and

adipose tissue. In: Neligan PC, ed. Plastic Surgery.
4th ed. London: Elsevier, 2017, with permission.) D.
The sterile graft material can be handled by placing it
in a vessel with a pour spout (E,F) and then filling
capped 30-cc syringe barrels from the back.
(Reproduced from Sivak WN, Rubin JP. Repair and
grafting fat and adipose tissue. In: Neligan PC, ed.
Plastic Surgery. 4th ed. London: Elsevier, 2017, with
permission.)
■ Fat Injection
■ Planned incision sites are anesthetized with 0.5% lidocaine with 1:200 000
epinephrine, and small stab incisions are made for the placement of fat
through 14- or 16-gauge injection cannulas.
■ A blunt-tipped injection cannula is connected to the 30-cc syringe (TECH
FIG 2A,B).
■ Three to four injection sites are used, and these can be placed inferiorly and
laterally so they are less visible.
■ The success of the fat grafting procedure depends not only on the harvesting
and refinement but also on the placement of the fat in a manner that increases
its chance for optimal survival.
TECH FIG 2 • A. For large-volume fat grafting, a 16-
gauge blunt-tipped cannula can be used with the 30-
cc syringes, (B) and the fat should be easily flowable.
(Reproduced from Sivak WN, Rubin JP. Repair and
grafting fat and adipose tissue. In: Neligan PC, ed.

Plastic Surgery. 4th ed. London: Elsevier, 2017, with
permission.)
TECH FIG 3 • A. 54-year-old woman 3 years status
post left breast quadrantectomy and radiation therapy
for invasive breast carcinoma. B. Patient shown 5
months status post fat grafting with scar release of the
left breast and concurrent reduction of left breast for
symmetry. (Reproduced from Sivak WN, Rubin JP.
Repair and grafting fat and adipose tissue. In: Neligan
PC, ed. Plastic Surgery. 4th ed. London: Elsevier,
2017, with permission.)
■ This means maximizing the contact surface area of the fatty parcel with the
surrounding tissue, such that a blood supply can be conferred to the newly
grafted fat.
■ Transferring large globules of fat can result in central necrosis of the mass
with subsequent resorption and loss of volume or possibly even cyst
formation.
■ The fat is gently placed during the withdrawal of a blunt infiltration cannula.
Recall fat can be placed at different levels to accomplish different effects—
determining where and at what level to place fat relies upon the skill and
experience of the surgeon.
■ Grafting fat immediately beneath the dermis can improve the quality of the
skin, decrease wrinkling, and decrease pore size and may even reduce
scarring.
■ Deeper injection within the breast can be used to increase central

projection.
■ Fat can be placed intramuscularly, as needed.
■ Structure should be purposefully built up with tiny aliquots of fat rather than
attempting to insert larger aliquots and then mold the tissue after it is placed.
■ Manual molding of the shape should be considered if an irregularity is noted
at the time of placement, as the surface must be smooth before leaving the
operating room.
■ The stab incisions used for placement of the fat can be closed with single
interrupted 5-0 fast-absorbing sutures.
■ Examples of large volume fat grafting are shown for lumpectomy defect
(TECH FIG 3), replacement of implants (TECH FIG 4), and cosmetic
mastopexy/augmentation (TECH FIG 5).

TECH FIG 4 • A–C. Removal of breast implants and
replacement with fat graft in the same procedure. This
48-year-old woman had severe right breast capsular
contracture with pain. This was a recurrent problem
for this patient. She presented for explantation of the
implants. (Reproduced from Sivak WN, Rubin JP.
Repair and grafting fat and adipose tissue. In: Neligan
PC, ed. Plastic Surgery. 4th ed. London: Elsevier,
2017, with permission.) D–F. Patient 18 months after
removal of 350-cc smooth round saline implants and
simultaneous grafting of 380cc of fat per breast.
(Reproduced from Sivak WN, Rubin JP. Repair and
grafting fat and adipose tissue. In: Neligan PC, ed.
Plastic Surgery. 4th ed. London: Elsevier, 2017, with
permission.)

TECH FIG 5 • A–C. A 34-year-old woman with ptosis
and asymmetry. Pre-existing flan scar is from a prior
upper body lift. D–F. She underwent bilateral
mastopexy with minimal parenchymal dissection and
350cc of fat grafting to the left breast to balance the
asymmetry in volume. Postoperative views are shown
at 4 months.
PEARLS AND PITFALLS
Fat harvest
■ The fat harvest is, in itself, a procedure that must be done in a manner
to avoid contour deformities and may also have aesthetic goals for
that anatomic region.
Fat
processing
■ A sterile liposuction canister can be kept on the field for easy and
efficient decanting.
■ Large-volume canisters that include filters and outflow ports are
commercially available.
■ Workflow efficiency is key for large-volume fat grafting.
Fat
injection
■ Injection of local anesthetic solution with epinephrine at the injection
site helps to reduce bruising.
■ Special care must be taken when placing fat superficially, as surface
irregularities are more apt to be apparent.

■ Breast injection port sites can be kept inferior and lateral so they are
less visible.
POSTOPERATIVE CARE
■ Care of the patient after fat grafting remains relatively simple.
■ A loosely fitting surgical bra keeps the patient comfortable and avoids
excessive pressure on the grafted sites.
■ Direct pressure upon the grafted area should be avoided for 1 month (no
sleeping on stomach).
■ Donor sites may be dressed with compression garments or an abdominal
binder if large volumes are harvested.
■ Preoperative antibiotics are used, along with 5 days of antibiotics
postoperatively.
OUTCOMES
■ With fat grafting, secondary procedures, or touch-up procedures, are always
possible because of unpredictable resorption.
■ Infiltration and swelling at the time of surgery, in addition to the
unpredictable resorption of fat, make the precise estimation of final volume
after healing difficult, especially when compared with silicone implants.
■ Patients should be instructed that multiple rounds of grafting might be
required to achieve the desired end result.
■ In reconstructive cases, the soft tissue envelope often limits the surgeon, and
as tissue quality improves after initial fat grafting, the area may become more
receptive to larger subsequent volumes.
■ It is far better to undercorrect a deficient area and return to the operating
room for a second stage, if necessary, at a later date, than to overfill the
tissues.
COMPLICATIONS
■ Fat grafting procedures to the breast by and large are deemed to be low risk
and are associated with low perioperative morbidity rates given proper patient
selection. Soreness and swelling are common, but not every patient will
experience them.
■ The most significant risk remains the unpredictable nature of the graft, where
the recipient site may simply reabsorb most of the transferred fat. The extent of
resorption at this time cannot be predicted for a given individual, but some

degree of resorption will happen in every patient.
■ Rare but possible fat transfer risks and complications include allergic reaction
to the local anesthetic, permanent discoloration caused by a ruptured blood
vessel, fat necrosis, oil cyst formation, calcification, overcorrection,
perioperative bleeding, hematoma at the treatment or donor site, a blood-borne
infection (more likely if combined with another cosmetic procedure), scarring,
and a fat embolism from direct fat injection into a blood vessel.
■ The most problematic is the high potential for contour irregularities visible
through the skin, which can occur in both the recipient and donor sites.
■ In the recipient sites, excess grafted fat will appear as lumps beneath the skin
and is generally the result of placement of a volume that is too large just
beneath thin skin.
■ Irregularities in the donor sites can be pronounced, particularly if too much
fat is removed from a single area.
■ Significant changes in weight can also result in related changes in the size of
the area grafted; therefore, patients are encouraged to have fat grafting
procedures performed when they are at their ideal body weight and to
maintain that weight indefinitely.
REFERENCES
1. Kling RE, et al. Trends in autologous fat grafting to the breast: a national
survey of the American Society of Plastic Surgeons. Plast Reconstr Surg.
2013;132(1):35-46.
2. Coleman SR. The technique of periorbital lipoinfiltration. Operat Tech Plast
Reconstr Sur. 1994;1(3):120-126.
3. Pu LL, et al. Autologous fat grafts harvested and refined by the Coleman
technique: a comparative study. Plast Reconstr Surg. 2008; 122(3):932-937.

34
CHAPTER
Section IX: Lyphedema
Lymphedema Microsurgery
for Breast Cancer–Related
Upper Limb Lymphedema
Ming-Huei Cheng and Jung-Ju Huang
DEFINITION
■ Lymphedema can be inherited or a complication after lymph node dissection.
Breast cancer–related lymphedema (BCRL) is a potential complication after
axillary lymph node dissection, particularly in patients who have or will
receive adjuvant radiation.
■ With the subcutaneous accumulation of lymphatic fluids, the typical early sign
of lymphedema is swelling of the affected limb. Occasionally, patients may
present with pain as the first symptom of lymphedema.
■ Definitive diagnosis can be confirmed by lymphoscintigraphy.
ANATOMY
■ There are approximately 600 to 700 lymph nodes located in a human body,
and the axilla is one of the most concentrated areas.
■ Axillary lymph node dissection (ALND), as a procedure for breast cancer
staging and treatment, often results in lymphedema of the upper extremity of
the affected site, which is exacerbated by radiation therapy.1,2
PATHOGENESIS
■ The lymphatic system maintains fluid homeostasis, absorbs dietary fat, and
facilitates the host immune response. Once disturbed, fluid homeostasis is
blocked and subsequent disease is initiated.

■ Unbalanced fluid homeostasis can cause protein-rich fluid to leak into the
interstitial tissue, resulting in swelling, local tissue inflammation, adipose
deposition, and fibrosis.
■ A compromised local immune defense makes a patient more susceptible to
infection, and repeated cellulitis is one of the common features of
lymphedema.
■ Although breast surgeons have reduced the frequency of axillary dissection
through the use of sentinel lymph node biopsy (SLNB), upper extremity
lymphedema can still occur after SLNB or ALND.
NATURAL HISTORY
■ BCRL is the major factor that compromises a breast cancer patient’s quality of
life after treatment.1
■ The presentation time and symptoms of lymphedema are highly variable
among patients.
■ Risk factors that contribute to the severity of lymphedema other than
radiotherapy include infection and obesity.
■ The incidence of BCRL ranges from 12% to 49%.1,2
■ As it differs from most traditional treatments that involve excision or other
destructive procedures, microsurgical treatment for lymphedema aims to drain
the accumulated fluid from the affected extremity.
■ Lymphaticovenous anastomosis (LVA) is the first microsurgery procedure to
treat lymphedema.
■ However, this approach has not been popular until recent years, as more
accurate diagnostic tools to identify lymphatic vessels have become available,
such as indocyanine green (ICG) lymphography. 3
■ Another microsurgical treatment is vascularized lymph node transfer, which
was first developed in an animal study in the 1990s.
■ The idea of transferring healthy, unaffected lymph nodes from other donor
sites to the affected extremities provides another approach for microsurgical
lymphatic fluid drainage once the lymphatic vessels are destroyed and LVA is
not possible.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Patients with BCRL may experience discomfort, swelling, and recurrent
cellulitis of the affected extremity.
■ The first sign of lymphedema is often swelling.

■ Occasionally, they present with intractable pain for an unknown reason or
with repeated cellulitis.
■ The resultant problems may become both a physical and psychosocial
problem.
■ Physical examinations of a lymphedema-affected extremity often reveal
nonpitting swelling and thickening of the skin (which can be peau d’orange
skin or even woody in more advanced stage).
■ It is not uncommon to find skin erosion or ulceration or signs of infection on
the skin.
■ Occasionally, brachial plexus dysfunction can occur.
■ With long-term involvement, the skin of the affected extremity can present
elephantiasis nostra verrucosa, which appears hyperkeratotic with
cobblestonelike skin and some papillomatous plaques.
■ Clear or light yellow fluid can ooze from the skin.
■ The tissue may become malodorous in the setting of poor hygiene.
IMAGING
■ Accurate diagnosis and grading of lymphedema help to identify suitable
treatments.
■ Measurement of the limb circumference and calculation of the difference
between the normal and diseased extremity often appears to be the first, easy
diagnostic tool.
■ The level for measurement by the authors includes 10 cm above and below
the elbow. The circumference difference can then be calculated accordingly
(FIG 1).
■ Lymphoscintigraphy remains the standard diagnosis for lymphedema.
■ With the injection of a tracer molecule with technetium-99m into the dermis
of a distal hand, the traveling of Tc-99 can be traced. Information regarding
the clearance of the injection tracer, obstruction status (such as total or partial
obstruction), and possible obstruction level/presentation of dermal backflow
can be provided.
■ With a similar injection technique, ICG (indocyanine) dye is intradermally
injected into the distal hand (often the 2nd and 4th web spaces).
■ With an infrared light source and diagnostic devices, such as PDE
(Hamamatsu Photonics, Hamamatsu City, Japan), SPY (Novadaq
Mississauga, Canada), and infrared detector–incorporated microscopy, the
traveling course of the ICG dye (mainly inside the lymphatic vessels) can be

identified. ICG lymphography provides a dynamic and panoramic view of the
lymphatic drainage with time. It is a powerful tool for both lymphedema
diagnosis and intraoperative planning for lymphatic surgery.
■ The main drawback is that the detection of the ICG is limited to
approximately 1 cm underneath the skin.
DIFFERENTIAL DIAGNOSIS
■ Diseases other than lymphedema can present with swelling of extremities,
such as mechanical obstruction and venous thromboembolism.
■ Ultrasonography to assess the status of venous drainage is recommended.
NONOPERATIVE MANAGEMENT
■ Nonoperative management strategies include manual massage, complex
decongestive physiotherapy (CDP), and compression garments.
FIG 1 • Measurement of volume differentiation of
circumference before (A) and after (B) lymphedema
surgery. To do this, the circumferences of the upper arm
and forearm are first measured at the level of 10 cm
above and below the elbow.
SURGICAL MANAGEMENT
■ Microsurgical treatment for BCRL includes LVA, vascularized lymph node
transfer (VLNT), and the combination of microsurgical breast reconstruction
and lymph node transfer using an abdominal flap with superficial groin lymph
node transfer.

■ A “Barcelona cocktail” is a combination of microsurgical breast
reconstruction with superficial groin lymph node transfer to the axilla and
LVA in the forearm, which aims to complete surgical treatment at one stage.
■ Early interventions provide better recovery because the pathological progress
of adipose deposition and fibrosis can be better prevented. This is especially
true when LVA is considered.
■ Microsurgical treatments may not achieve the same degree of volume
reduction as liposuction; instead, they gradually stop the disease progression by
effectively draining lymphatic fluid into the venous system.
■ Patients with fibrosis may still benefit from surgery with adjuvant
procedures, such as liposuction and/or partial soft tissue resection.
■ The selection of treatment is based on the severity of lymphatic obstruction
and clinical symptoms (FIG 2).
Lymphaticovenous Anastomosis
■ Technological advancements in diagnosis and mapping have allowed LVA to
become a popular procedure for lymphedema treatment in early-grade cases
with promising results.
■ Different surgeons have different preferences for performing LVA, including
the method (end-to-end, end-to-side, and side-to-end), locations, and numbers
of LVAs that have to be done.
■ Supramicrosurgery, including anastomosis of vessels as small as 0.8 mm or
less to small subdermal veins, has been recommended.4 To prevent
postoperative venous reflux, a suitable recipient vein should present with
minimal backflow after it is cut. Strong backflow from the subdermal veins
may result in venous blood backflowing into the lymphatics. This results in a
limited chance for lymphedema recovery, ecchymosis, and discomfort.
Vascularized Lymph Node Transfer
■ VLNT can be effective in patients with different stages of lymphedema,
including advanced stage.5,6
■ There are two different theories supporting its mechanism for lymphatic
drainage.
■ One is based on lymphangiogenesis and spontaneous lymphatic connection.7
■ The other is based on the inherent lymphaticovenous connection inside the
flap.8

■ Cheng and colleagues demonstrated in animal studies and intraoperative
images evidence to support their theory of this mechanism.9 By injection of
ICG dye into the subcutaneous tissue of lymph node containing flaps, ICG is
eventually drained via the flap donor vein.
■ Conversely, drainage is absent when the dye is injected into non–lymph node-
containing flap.9 They have demonstrated that the inherent lymphaticovenous
connection is the main mechanism for lymphatic drainage. Combined with
“catchment effect” and “gravity” effect, VLNT placed in the distal recipient
site would offer the most benefit for lymphatic drainage.
FIG 2 • Algorithm for surgical approaches of breast
cancer–related lymphedema (BCRL).
Preoperative Planning
■ Cheng and colleagues developed a disease grading system that includes both
clinical symptoms and diagnostic results from lymphoscintigraphy6 (Table 1).

Based on the staging system, patients are graded from 0 to IV according to the
lymphedema severity.
■ By combing preoperative symptoms and diagnostic findings, mainly
lymphoscintigraphy and ICG lymphography, an algorithm has been developed
to more accurately assign the patients to appropriate treatment (see FIG 2).
■ If the lymphatic obstruction is partial and functional lymphatic vessels can
still be identified in ICG lymphography, LVA can be considered a good
surgical option.
■ However, if the lymphatic obstruction is complete and functional lymphatics
are not identifiable, VLNT is the best surgical option.
■ Patients who have stage III or IV lymphedema usually require additional
procedures other than microsurgical treatment to optimize the results.
■ Patients showing a linear pattern of lymphatic vessels with ICG lymphography
can be selected for LVA with predictably good outcomes.
■ The preoperative use of duplex ultrasonography aids in the selection of the
optimal flap for VLNT.8 Additionally, duplex ultrasonography can be useful in
determining recipient vessels for VLNT.8
■ More detailed preoperative examinations, such as computer tomography (CT)
scan or magnetic resonance imaging (MRI), can be helpful to further
differentiate the disease pathology and identify the donor and recipient vessel
quality.
Positioning
■ Patients are in the supine position for both LVA and VLNT.
■ Hyperextension of the neck is required if submental lymph node flaps or
transverse cervical lymph nodes are selected as donor sites.
Approach
■ For LVA, surgical approach includes one to several 3-cm incisions, depending
on preoperative ICG lymphography.
■ Surgical approach for VLNT includes flap harvest and recipient site
preparation. There are many donor flaps for VLNT depending on preoperative
evaluation and the surgeon’s preference. Advance selection of appropriate
recipient site is equally important (proximal vs distal on the extremity).
■ Some surgeons place the VLNT into the axilla where a previous axillary scar
exists. The scar will need to be fully released during VLNT. However, we