The Art of Aesthetic Surgery Principles and Techniques Three Volume Set Second Edition

2270
Part XI  Breast Surgery
McLaughlin JK. Do cosmetic breast implants cause suicide? Plast Reconstr Surg 112:1721-
1723, 2003.
Mladick R. Textured silicone breast implants. Plast Reconstr Surg 110:1201-1202, 2002.
Nahabedian MY, Tsangaris T, Momen B, et al. Infectious complications following breast re-
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2271
Chapter 62  Breast Augmentation
Smooth Round
Moderate Profile
Style 1600
Device
A
B
A
B
Volume
Diameter
Projection
Diameter
Projection
(cc)
(cm)
(cm)
(cm)
(cm)
125  25
9.5
3.0
9.1
3.4
150  25
10.0
3.1
9.6
3.7
175  25
10.6
3.3
10.0
3.9
200  25
11.0
3.4
10.4
3.9
225  25
11.5
3.5
10.9
4.0
250  25
11.9
3.6
11.2
4.1
275  25
12.3
3.7
11.7
4.2
300  25
12.6
3.7
12.1
4.3
325  50
13.0
3.8
12.3
4.5
350  50
13.3
3.9
12.6
4.7
375  50
13.6
4.0
12.8
4.8
425  50
14.2
4.1
13.5
4.9
475  50
14.8
4.2
14.2
4.9
525  50
15.0
4.2
14.5
5.1
575  50
15.0
4.5
14.8
5.1
625  75
15.2
4.6
14.9
5.6
700  75
15.6
4.9
14.9
5.8
Nominal Fill
Maximum Fill
A
B
A
B
Volume
Diameter
Projection
Diameter
Projection
(cc)
(cm)
(cm)
(cm)
(cm)
175  35
9.5
3.5
9.3
4.2
200  40
10.0
3.7
9.7
4.4
225  45
10.4
3.8
10.1
4.6
250  50
10.8
4.0
10.5
4.7
275  55
11.0
4.1
10.8
4.9
300  60
11.5
4.3
11.2
5.0
325  65
11.9
4.4
11.5
5.2
350  70
12.1
4.5
11.7
5.3
375  75
12.3
4.6
12.0
5.4
400  80
12.6
4.7
12.3
5.5
425  85
12.9
4.8
12.5
5.6
450  90
13.0
4.9
12.8
5.7
475  95
13.3
5.0
13.0
5.8
500  100
13.6
5.1
13.2
5.9
550  110
14.0
5.3
13.7
6.1
600  120
14.5
5.5
14.1
6.3
650  130
14.8
5.6
14.4
6.5
700  140
15.2
5.8
14.8
6.6
750  150
15.6
5.9
15.1
6.8
800  160
16.1
6.0
15.5
7.0
Nominal Fill
Maximum Fill
Smooth Round
Moderate Plus Profile
Style 2000
A
B
A
B
Volume
Diameter
Projection
Diameter
Projection
(cc)
(cm)
(cm)
(cm)
(cm)
170  30
9.0
4.0
8.8
4.9
190  35
9.3
4.1
9.1
5.1
210  40
9.6
4.2
9.5
5.3
230  45
10.0
4.3
9.8
5.5
250  50
10.2
4.5
10.0
5.6
270  55
10.4
4.6
10.2
5.8
290  60
10.8
4.7
10.5
5.9
310  65
11.0
4.8
10.7
6.0
330  70
11.3
4.8
11.0
6.2
380  70
11.7
5.2
11.4
6.4
420  80
12.0
5.4
11.7
6.7
460  90
12.4
5.5
12.1
6.9
500  100
12.8
5.6
12.4
7.1
560  115
13.4
5.7
13.1
7.3
630  120
13.8
5.9
13.4
7.4
Nominal Fill
Maximum Fill
Smooth Round
High Profile
Style 3000
A
B
A
B
A
B
APPENDIX: IMPLANT OPTIONS
Saline Implants—Smooth (Mentor)

2272
Part XI  Breast Surgery
Saline Implants—Smooth (Allergan)
A
B
A
B
Volume
Diameter
Projection
Diameter
Projection
(cc)
(cm)
(cm)
(cm)
(cm)
125-145
9.5
2.6
9.3
3.2
150-170
10.0
2.7
9.9
3.2
175-195
10.6
2.8
10.4
3.3
200-220
11.0
3.0
10.9
3.4
225-245
11.4
3.1
11.3
3.4
250-270
11.9
3.2
11.7
3.5
275-295
12.2
3.3
12.1
3.6
300-320
12.5
3.4
12.4
3.7
325-345
12.9
3.5
12.7
3.8
350-370
13.3
3.6
13.2
3.8
400-420
13.5
3.8
13.4
4.2
420-440
13.9
3.9
13.8
4.1
440-460
14.2
3.9
14.1
4.1
480-500
14.5
4.0
14.4
4.3
525-545
14.8
4.2
14.7
4.5
550-570
15.1
4.3
15.0
4.5
600-620
15.4
4.4
15.3
4.6
640-660
15.8
4.5
15.7
4.7
680-700
16.2
4.5
16.1
4.7
Minimum Dimensions
Maximum Dimensions
Smooth Round
Low Profile
Style 68LP
A
B
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
120-150
9.0
3.0
150-180
9.6
3.3
180-210
10.2
3.4
210-240
10.6
3.7
240-270
11.1
3.8
270-300
11.6
3.9
300-330
11.9
4.1
330-360
12.3
4.2
360-390
12.7
4.2
390-420
13.0
4.5
420-450
13.4
4.5
450-480
13.7
4.6
480-510
14.1
4.6
510-540
14.4
4.6
550-600
14.6
4.9
600-650
15.0
5.0
650-700
15.2
5.3
700-750
15.6
5.4
750-800
15.9
5.6
800-850
16.4
5.6
Minimum Dimensions
Smooth Round
Moderate Profile
Style 68MP
A
B
A
B
Volume
Diameter
Projection
Diameter
Projection
(cc)
(cm)
(cm)
(cm)
(cm)
160-175
9.0
3.9
8.8
4.3
200-220
9.6
4.2
9.5
4.6
240-260
10.2
4.4
10.0
5.0
280-300
10.6
4.7
10.5
5.2
320-340
11.1
4.9
11.0
5.3
350-380
11.6
4.9
11.4
5.5
400-430
11.9
5.0
11.7
5.9
425-455
12.3
5.3
12.1
5.9
465-505
12.6
5.6
12.5
6.1
500-540
13.0
5.7
12.8
6.3
550-590
13.3
5.8
13.1
6.4
600-640
13.7
6.0
13.5
6.6
650-700
14.0
6.1
13.8
6.9
700-750
14.4
6.2
14.1
7.1
750-800
14.6
6.5
14.4
7.2
800-850
15.0
6.7
14.7
7.2
Minimum Dimensions
Maximum Dimensions
Smooth Round
High Profile
Style 68HP
A
B
A
B

2273
Chapter 62  Breast Augmentation
Saline Implants—Textured (Mentor)
Saline Implants—Textured (Allergan)
A
B
A
B
Volume
Diameter
Projection
Diameter
Projection
(cc)
(cm)
(cm)
(cm)
(cm)
125  25
9.5
3.0
9.1
3.4
150  25
10.0
3.1
9.6
3.7
175  25
10.6
3.3
10.0
3.9
200  25
11.0
3.4
10.4
3.9
225  25
11.5
3.5
10.9
4.0
250  25
11.9
3.6
11.2
4.1
275  25
12.3
3.7
11.7
4.2
300  25
12.6
3.7
12.1
4.3
325  50
13.0
3.8
12.3
4.5
350  50
13.3
3.9
12.6
4.7
375  50
13.6
4.0
12.8
4.8
425  50
14.2
4.1
13.5
4.9
475  50
14.8
4.2
14.2
4.9
Nominal Fill
Maximum Fill
Siltex® Round
Moderate Profile
Style 2600
A
B
C
Volume
Width
Height
Projection
(cc)
(cm)
(cm)
(cm)
175  25
10.2
8.5
4.3
225  25
11.2
9.4
4.5
275  25
12.2
10.3
4.5
350  50
13.1
11.0
4.7
425  50
13.8
11.6
5.2
525  50
14.9
12.5
5.6
Siltex® Contour Profile®
Moderate
Style 2900
Siltex® Contour Profile®
High
Style 2700
A
B
C
Volume
Width
Height
Projection
(cc)
(cm)
(cm)
(cm)
275  25
11.5
9.5
5.1
350  50
12.3
10.5
5.3
450  50
13.2
11.0
6.1
550  50
14.0
11.9
6.4
650  75
15.0
12.7
6.6
A
B
Volume
Width
Projection
(cc)
(cm)
(cm)
120-150
9.0
3.0
150-180
9.6
3.3
180-210
10.2
3.4
210-240
10.6
3.7
240-270
11.1
3.8
270-300
11.6
3.9
300-330
11.9
4.1
330-360
12.3
4.2
360-390
12.7
4.2
390-420
13.0
4.5
420-450
13.4
4.5
450-480
13.7
4.6
480-510
14.1
4.6
510-540
14.4
4.6
550-600
14.6
4.9
600-650
15.0
5.0
650-700
15.2
5.3
700-750
15.6
5.4
750-800
15.9
5.6
800-850
16.4
5.6
A
B
C
Volume
Width
Height
Projection
(cc)
(cm)
(cm)
(cm)
170-180
10.4
8.6
4.2
200-210
10.8
9.0
4.5
230-240
11.2
9.4
4.7
260-275
11.8
9.8
4.9
300-315
12.2
10.2
5.1
330-350
12.6
10.6
5.3
370-390
13.0
11.0
5.5
410-430
13.6
11.4
5.6
450-475
14.0
11.8
5.8
510-535
14.4
12.2
6.1
560-585
15.0
12.6
6.2
620-645
15.4
13.0
6.5
690-720
15.8
13.4
6.8
BIOCELL® Shaped
Low Height
Style 363LF
A
B
C
Volume
Width
Height
Projection
(cc)
(cm)
(cm)
(cm)
195-205
10.0
10.5
4.0
230-240
10.5
11.0
4.2
270-285
11.0
11.5
4.3
300-315
11.5
12.0
4.6
350-370
12.0
12.5
4.8
380-400
12.5
13.0
4.9
450-475
13.0
13.5
5.3
495-520
13.5
14.0
5.5
560-590
14.0
14.5
5.7
620-650
14.5
15.0
5.9
BIOCELL® Shaped
Full Height
Style 468
A
B
A
C
B
A
B
A
C
B
A
C
B
A
C
B
BIOCELL®
Round Moderate
Profile Style 168

2274
Part XI  Breast Surgery
Gel-Filled Implants—Smooth (Mentor)
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
100
9.3
2.1
125
10.0
2.2
150
10.3
2.3
175
11.2
2.4
200
11.7
2.5
225
12.2
2.6
250
12.3
2.8
275
13.2
2.9
300
13.5
3.0
325
13.9
3.0
350
14.2
3.1
375
14.4
3.2
400
14.5
3.2
450
14.9
3.4
500
15.2
3.6
550
15.9
3.6
600
16.5
3.7
700
17.4
3.9
800
18.2
4.1
Smooth Round
Moderate Profile
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
100
8.2
2.7
125
8.9
2.8
150
9.5
2.9
175
10.0
3.1
200
10.5
3.2
225
10.9
3.3
250
11.3
3.4
275
11.7
3.5
300
12.0
3.6
325
12.3
3.8
350
12.5
4.0
375
12.8
4.0
400
13.1
4.0
425
13.4
4.1
450
13.6
4.2
475
13.9
4.2
500
14.1
4.3
525
14.3
4.4
550
14.6
4.5
575
14.8
4.5
600
15.0
4.6
650
15.4
4.7
700
15.8
4.9
750
16.1
5.0
800
16.5
5.1
Smooth Round
Moderate Plus
Profile
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
125
8.3
3.5
150
8.8
3.7
175
9.3
3.9
200
9.7
4.0
225
10.1
4.2
250
10.5
4.3
275
10.8
4.4
300
11.1
4.5
325
11.4
4.6
350
11.7
4.8
375
12.0
4.8
400
12.2
5.0
425
12.5
5.0
450
12.8
5.1
475
13.0
5.3
500
13.2
5.3
550
13.6
5.5
600
14.0
5.6
650
14.4
5.7
700
14.8
5.8
750
15.2
5.9
800
15.5
6.0
Smooth Round
High Profile
A
B
A
B
A
B

2275
Chapter 62  Breast Augmentation
Gel-Filled Implants—Smooth (Allergan)
A
B
A
B
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
120
9.4
2.5
150
10.1
2.7
180
10.7
2.9
210
11.2
3.0
240
11.7
3.2
270
12.2
3.3
300
12.6
3.5
330
13.0
3.6
360
13.4
3.7
390
13.6
3.8
420
14.0
3.8
450
14.4
3.9
480
14.8
3.9
510
15.1
4.0
550
15.4
4.0
600
15.8
4.3
650
16.0
4.5
700
16.4
4.6
750
16.8
4.8
800
17.2
4.9
Smooth Round
Moderate Profile
Style 10
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
158
9.5
3.2
176
9.9
3.3
194
10.3
3.4
213
10.6
3.5
234
10.9
3.6
265
11.4
3.7
286
11.7
3.8
304
11.9
4.0
339
12.4
4.0
371
12.9
4.1
397
13.1
4.2
421
13.3
4.3
457
13.7
4.5
492
14.0
4.6
533
14.4
4.7
575
14.8
4.8
616
15.2
4.9
659
15.4
5.0
700
15.8
5.1
752
16.2
5.2
Smooth Round
Midrange Profile
Style 15
A
B
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
120
9.0
2.7
140
9.1
3.3
160
9.4
3.5
180
9.6
3.8
200
9.7
4.0
230
10.0
4.2
260
10.4
4.3
280
10.6
4.5
300
10.9
4.5
325
11.2
4.6
350
11.4
4.9
375
11.7
4.9
400
11.9
5.0
425
12.0
5.2
450
12.4
5.2
475
12.6
5.5
500
13.0
5.2
550
13.5
5.6
600
13.6
5.7
650
14.2
5.9
700
14.5
6.2
750
15.0
6.0
800
15.3
6.1
Smooth Round
High Profile
Style 20
A
B
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
80
8.8
1.7
100
8.9
2.2
120
9.1
2.5
140
9.4
2.7
160
9.7
3.1
180
10.0
3.3
200
10.2
3.5
220
10.5
3.6
240
10.9
3.7
260
11.2
3.8
280
11.4
3.8
300
11.7
3.9
320
12.0
3.9
340
12.3
4.0
360
12.5
4.1
400
12.7
4.2
460
13.8
4.2
500
14.2
4.3
560
14.7
4.6
Smooth Round
Moderate Profile
Style 40
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
120
7.4
3.6
160
8.2
3.7
200
9.0
4.1
240
9.6
4.3
280
10.0
4.6
320
10.4
4.8
360
10.8
5.1
400
11.2
5.1
460
11.4
5.9
500
11.9
5.7
550
12.4
6.0
600
12.8
6.1
650
13.2
6.2
700
13.5
6.4
800
14.2
6.7
Smooth Round
Full Profile
Style 45
A
B

2276
Part XI  Breast Surgery
Gel-Filled Implants—Textured (Mentor)
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
100
8.8
2.5
125
9.3
2.8
150
10.2
2.7
175
10.7
2.8
200
11.2
2.8
225
11.4
3.0
250
11.5
3.3
275
12.4
3.4
300
12.6
3.5
325
12.9
3.6
350
13.4
3.7
375
13.4
3.8
400
13.5
3.9
450
13.9
4.1
500
14.2
4.3
550
14.8
4.4
600
15.4
4.5
700
16.8
4.3
800
17.2
4.6
Siltex® Round
Moderate Profile
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
100
8.1
2.7
125
8.8
2.9
150
9.4
3.0
175
10.0
3.2
200
10.5
3.3
225
10.9
3.5
250
11.3
3.6
275
11.7
3.7
300
12.0
3.7
325
12.3
3.8
350
12.6
3.8
375
12.9
3.9
400
13.2
4.0
425
13.4
4.1
450
13.7
4.1
475
13.9
4.2
500
14.1
4.2
525
14.3
4.3
550
14.4
4.4
575
14.8
4.4
600
14.7
4.5
650
15.4
4.6
700
15.7
4.8
750
16.1
4.9
800
16.6
5.0
Siltex® Round
Moderate Plus
Profile
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
125
8.4
3.6
150
8.9
3.8
175
9.4
4.0
200
9.9
4.1
225
10.2
4.3
250
10.5
4.5
275
10.9
4.6
300
11.1
4.7
325
11.5
4.8
350
11.7
4.9
375
12.0
5.0
400
12.3
5.1
425
12.5
5.2
450
12.7
5.2
475
13.0
5.2
500
13.2
5.4
550
13.5
5.6
600
14.0
5.7
650
14.3
5.8
700
14.7
6.0
750
15.2
5.9
800
15.4
6.3
Siltex® Round
High Profile
A
B
A
B
A
B
Gel-Filled Implants—Textured (Allergan)
A
B
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
90
8.7
2.0
120
9.0
2.4
150
9.7
2.5
180
10.3
2.7
210
11.1
2.8
240
11.7
2.9
270
12.3
3.0
300
12.6
3.1
330
12.8
3.1
360
13.5
3.2
390
13.7
3.2
420
13.9
3.3
450
14.3
3.3
480
15.1
3.3
510
15.5
3.4
BIOCELL® Round
Moderate Profile
Style 110
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
150
9.7
3.1
167
10.0
3.2
185
10.4
3.3
203
10.7
3.3
222
11.0
3.5
253
11.6
3.6
272
11.8
3.7
290
12.0
3.8
322
12.5
3.9
354
13.0
4.0
378
13.2
4.1
401
13.4
4.2
435
13.8
4.3
469
14.1
4.4
507
14.5
4.5
547
14.9
4.5
586
15.3
4.6
627
15.6
4.8
666
16.0
4.9
716
16.4
5.0
BIOCELL® Round
Midrange Profile
Style 115
A
B
A
B
Volume
Diameter
Projection
(cc)
(cm)
(cm)
180
9.4
3.3
220
9.9
3.7
260
10.6
4.0
300
11.0
4.2
340
11.5
4.3
400
12.1
4.5
440
12.7
4.6
500
13.5
4.7
550
13.9
4.8
600
14.5
4.9
650
15.5
5.0
BIOCELL® Round
High Profile
Style 120
A
B

2277
Chapter 62  Breast Augmentation
Saline Postoperatively Adjustable Implants (Mentor)
This product serves as both an expander and an implant.
Temporary
Final
A
B
Final
A
B
Volume
Volume
Volume
Diameter
Projection
Volume
Diameter
Projection
(cc)
(cc)
(cc)
(cm)
(cm)
(cc)
(cm)
(cm)
125
105
125
9.4
2.7
150
9.3
3.2
175
150
175
10.3
3.1
210
10.2
3.8
225
190
225
10.8
3.5
270
10.9
4.3
275
230
275
11.6
3.8
330
11.5
4.6
325
275
325
12.4
4.0
390
12.1
4.9
375
320
375
13.5
4.1
450
13.0
4.9
425
360
425
14.0
4.2
510
13.7
4.8
475
405
475
14.3
4.4
570
13.8
5.4
525
450
525
15.0
4.4
630
14.4
5.6
575
490
575
14.7
4.8
690
14.2
6.0
Minimum
Maximum
Spectrum® Postoperatively Adjustable
Smooth Round, Style 1400
Temporary
Final
A
B
Final
A
B
Volume
Volume
Volume
Diameter
Projection
Volume
Diameter
Projection
(cc)
(cc)
(cc)
(cm)
(cm)
(cc)
(cm)
(cm)
125
105
125
9.4
3.0
150
9.2
3.5
175
150
175
10.5
3.1
210
10.4
3.9
225
190
225
11.3
3.3
270
11.1
4.2
275
235
275
12.0
3.6
330
11.4
4.4
325
275
325
12.9
3.7
390
12.6
4.5
375
320
375
13.4
3.9
450
13.1
4.8
425
360
425
14.0
4.2
510
13.6
5.0
475
400
475
14.5
4.5
570
14.2
5.7
Minimum
Maximum
Spectrum® Postoperatively Adjustable
Siltex® Round, Style 2400
Temporary
Final
A
B
C
Final
A
B
C
Volume
Volume
Volume
Width
Height
Projection
Volume
Width
Height
Projection
(cc)
(cc)
(cc)
(cm)
(cm)
(cm)
(cc)
(cm)
(cm)
(cm)
275
235
275
11.5
9.5
5.1
330
11.1
9.4
6.3
350
300
350
12.3
10.5
5.3
420
11.9
10.1
6.9
450
380
450
13.2
11.0
6.1
540
12.7
11.0
7.5
550
470
550
14.0
11.9
6.4
660
13.7
11.9
7.9
650
550
650
15.0
12.7
6.6
780
14.5
12.5
8.2
Minimum
Maximum
Spectrum® Postoperatively Adjustable
Siltex® Contour Profile®, Style 2500
A
C
B
A
B
A
B

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Fat Grafting to the Breast

EMMANUEL DELAY, MICHEL MOUTRAN
CHAPTER 63

2280
Part XI  Breast Surgery
T
ransferring fat from body areas where it is present in excess (as in the abdomen
and thighs) to the breast for cosmetic and aesthetic purposes is not a new con-
cept. This approach has been considered since the very beginning of liposuction, par-
ticularly after publications by Illouz and Fournier. However, the concept remained
controversial and did not become widely used until the development of more pre-
cise tools and techniques. It was feared that autologous fat transfer would generate
fat necrosis and calcifications that at that time could not be readily assessed because
of the limitations of available imaging modalities.
Fat grafting regained popularity after the confirmation by Coleman that fat tissue
can be transplanted safely if meticulous care is exercised in the preparation and trans-
fer of fat cells. Coleman’s preliminary work was mainly on facial rejuvenation. In
1998, given the proven efficacy of fat transfer to the face for facial rejuvenation or
postsurgery reconstruction, we developed a research program to evaluate the effi-
cacy and safety of the procedure for thoracomammary reconstruction. We adapted
the technique for breast procedures and named it lipomodeling. We assessed its ef-
ficacy and tolerance in patients and demonstrated an absence of significant clinical
or radiologic signs of adverse effects.
In this chapter we present the evolution of ideas and the progress of knowledge about
fat grafting to the breast, describe its indications and contraindications, and high-
light its advantages and disadvantages. We also present some of our results obtained
with this promising technique.
Evolution of Technique
First Attempts
Fat grafting for breast plastic surgery has long been advocated by prominent sur-
geons. In 1895 Czerny described the first clinical case of breast reconstruction by
transplantation of a giant lipoma of the buttock region to the left breast. Adipose
cells were used to fill the void left in the breast after tumor resection in a patient
with a fibroadenoma. Some investigators performed breast reconstruction or aug-
mentation using fasciocutaneous flaps, gluteous fat implants, or local pedicled flaps.
Others have injected fat either directly into the breast or into previously inserted im-
plants. Some have even reported the cases of women undergoing augmentation
mammaplasty with cadaver fat allografts. However, tolerance of fat allografts is
poor, and all of these grafts had to be removed eventually because of inflammatory
reactions, sometimes after several years. In 1991 Fournier described the fat grafting
technique he used in patients who did not want a prosthesis and who requested only
moderate breast augmentation. The quantity of fat grafted to these patients was be-
tween 100 and 250 cc, injected in the retroglandular space, not in the mammary
parenchyma.

The Controversy
Fat grafting to the breasts has been highly controversial since the presentation by
Bircoll, first in Bangkok in 1984, then at the California Society of Plastic Surgeons in
1985, of a patient undergoing breast augmentation by injection of fat cells obtained
by liposuction. The patient was a 20-year-old woman who requested a moderate
augmentation of her breasts while undergoing fat grafting to repair the damage
caused by a dog bite. Bircoll and Novack considered that the technique should only
be used for women requesting moderate augmentation because of the potential risk
of necrosis when large quantities of fat were grafted. In 1987 Bircoll reported the
principal advantages of the procedure: its simplicity, the absence of a scar, and rapid
recovery. In addition, a prosthesis was not necessary and thus prosthesis-related com-
plications were avoided. He also noted the positive slimming effects at the harvest
site. Bircoll and Novack reported the case of a patient undergoing bilateral fat graft-
ing after unilateral reconstruction by TRAM flap; the fat grafting improved the aes-
thetic results and symmetry. The two papers triggered reactions from the medical
community; many expressed strong disapproval, citing the possibly that autologous
fat injections in the breasts could generate microcalcifications and cysts that could
potentially interfere with the detection of early breast carcinoma. Bircoll argued that
cancer-related calcifications and those following fat transplantation occur in differ-
ent sites and have different radiologic aspects and therefore cannot be mistaken, and
further, that breast reduction surgery also results in microcalcifications. But in 1987,
the Ad-Hoc Committee on New Procedures of the American Society of Plastic and
Reconstructive Surgeons issued a position paper that stated, “The committee is unan-
imous in deploring the use of autologous fat injection in breast augmentation,” and
further, that “much of the injected fat will not survive, and the known physiologic
response to necrosis of this tissue is scarring and calcification. As a result, detection
of early breast carcinoma through xerography and mammography will become dif-
ficult and the presence of disease may go undiscovered.”
There was no reference in the paper to scientific findings, and the report expressed
only the opinion of the members of the committee. Despite the paucity of scientific
information, and although it had long been recognized that any mammary surgery
can cause oily cysts or mammographic changes, the injection of fat into the breasts
became taboo among surgeons, limiting research and experimentation on this topic.
Ironically, in the same journal in 1987, Brown et al published a retrospective study
of mammographic changes after breast reduction, reporting that calcifications were
detectable in 50% of all mammograms at 2 years after surgery. The authors insisted
that in most cases these benign calcifications were easily distinguishable from changes
associated with cancer. Despite this high incidence of calcifications and the risk that
mammographic abnormalities might interfere with cancer detection, there was no
subsequent discussion of discontinuing breast reduction mammaplasties on the ba-
sis that such a procedure might interfere with breast cancer detection.
2281
Chapter 63  Fat Grafting to the Breast

2282
Part XI  Breast Surgery
Lifting the Taboo
Fat grafting had proved very efficient for facial rejuvenation and for the correction
of facial deformities. Thus in 1998 we focused our research on the subject and
adapted the technique to breast reconstruction. First, we used fat grafting in con-
junction with autologous latissimus dorsi flap reconstruction. This flap reconstruc-
tion, previously developed by our surgical unit, allowed satisfactory reconstruction
in 70% of cases, but the other 30% resulted in insufficient breast volume. Reduc-
tion of the contralateral breast was needed, or else a prosthesis had to be inserted,
which was precisely what we wanted to avoid in the first place, because the procedure
would no longer be autologous and because of the drawbacks associated with pros-
theses (unnatural shape and texture and the need to replace the prosthesis at some
point).
We started using fat grafting in patients undergoing autologous latissimus dorsi flap
reconstruction who were at low risk of local recurrence. We named the technique
lipomodeling, from the Greek root lipo for “fat,” and the Latin modello, “to give
shape or volume,” which is exactly the objective of this procedure. At first we used
the fat grafting technique only on 20 volunteer patients who agreed to undergo strict
initial follow-up for 1 year. After the efficacy of the technique had been demon-
strated, with results yielding optimal shape and texture as well as a natural décol-
leté, we proposed lipomodeling to almost all patients treated by latissimus dorsi flap
reconstruction. The study of mammography, CT scan, and MRI findings conducted
on patients in parallel demonstrated that fat grafting did not interfere with our abil-
ity to perform imaging studies on the patients. It was thus progressively extended
to other indications of breast reconstruction, then to the correction of breast defor-
mities, and finally to the treatment of sequelae of conservative treatments. Our first
presentations at the Société Française de Chirurgie Plastique Reconstructrice et Es-
thétique and the International Confederation for Plastic Reconstructive and Aes-
thetic Surgery raised considerable controversy, of the same order as the criticisms
made in 1987. Point-by-point debate gradually overcame the skepticism of the clin-
ical community, and fat grafting has now become a standard procedure in breast
reconstruction.
Indications
Lipomodeling of the breast and chest wall has many indications. It has been of great
benefit in reconstructive breast surgery. In aesthetic breast surgery and in selected
cases, fat transfer precludes the need for an implant (augmentation, and mastopexy
with a slight lack of fullness in the upper pole). It can also efficiently correct certain
defects of implant augmentation. Fat grafting has become a standard and useful pro-
cedure for enhancing the outcomes of breast aesthetic surgery.

Patient Profiles
Poland’s Syndrome
2283
Chapter 63  Fat Grafting to the Breast
Correction of the deformities of the breast and thorax associated with Poland’s syn-
drome remains a daunting challenge. Lipomodeling appears to be very effective in
these cases. Breast rehabilitation with fat grafting only leads to excellent outcomes
with simple but repeated procedures, resulting in very limited scarring and donor
site morbidity. We have treated 16 patients with different severities of Poland’s syn-
drome, among them 14 requiring lipomodeling alone and 2 treated with a combi-
nation of lipomodeling and pedicle flap reconstruction. In this series, three sessions,
on average, were required to obtain the desired result, with a mean of 244 cc in-
jected during each session. The results were notable: it was possible to restore the
breast, giving it a shape almost identical to that of the contralateral breast. The intro-
duction of this technique appears to be a major breakthrough for the management
of thorax and breast deformities in patients with Poland’s syndrome.
Pectus Excavatum
Pectus excavatum is a complex deformity with hollowing of the anterior sternocostal
wall; it usually has little or no impact on respiratory function. Most patients are
principally concerned about structure and aesthetics when there is significant defor-
mity of the breast, especially in severe or lateralized pectus excavatum. Fat transfer
techniques can be used alone to produce satisfactory correction for mild to moder-
ate forms, or in association with a custom-made rigid implant (based on three-
dimensional CT images) for more severe forms.

Tuberous Breasts
2284
Part XI  Breast Surgery
Tuberous breast deformity is an uncommon breast anomaly in which there is a con-
striction in the lower pole of the breast. It becomes apparent at puberty with the
growth of the breast. Various surgical approaches have been described, and a wide
range of techniques are available to produce an optimal result. Among them, lipo-
modeling can correct the lack of volume (especially if this is unilateral) and improve
the base and shape of the breast. It is a very useful adjunct in the treatment of tuber-
ous breasts. Recently Coleman reported encouraging results in patients with tuber-
ous breast deformity treated by fat injection.
The ideal indication is a unilateral hypoplastic tuberous breast (which usually re-
quires two fat transfer sessions) associated with a lack of fullness of the upper pole.
In cases of bilateral breast hypoplasia associated with tuberous deformity, implants
remain the standard treatment, unless the condition is associated with sufficient
lower body adiposity to augment the two breasts satisfactorily. Lipomodeling can
significantly enhance the results of these corrections by improving the décolleté area.
Asymmetrical Breasts
Asymmetry is a difficult problem when one breast has satisfactory fullness and per-
fect shape and the other is hypoplastic. Conventionally, augmentation with an im-
plant in the underdeveloped breast is the standard treatment. Although the initial
results of this approach are generally satisfactory, asymmetry of shape and volume
often reappears several years later. In this indication, lipomodeling yields a breast

very similar to the normal breast, and the change over time is natural, particularly
in regard to ptosis. Depending on the degree of asymmetry and hypoplasia, one to
three fat transfer sessions will be needed for an optimal result.
Bilateral Breast Augmentation
Lipomodeling in aesthetic surgery is developing rapidly. Our studies have shown
that if lipomodeling is carried out according to the technique we describe in this
chapter, it does not generate radiologic images that raise problems of differential di-
agnosis with breast malignancy or problems of radiologic follow-up for radiologists
who specialize in breast imaging.
The main radiologic risk is that breast cancer may occur coincident with lipomodel-
ing. To reduce this risk, imaging studies (mammography and ultrasonography) are
carried out before lipomodeling by a specialized radiologist to confirm the absence
of any suspicious lesions. If there is any doubt, lipomodeling is deferred or con-
traindicated. The radiologist must concur before lipomodeling is performed and
thereby becomes co-responsible for the follow-up. The patient gives written consent
to undergo the same studies by the same radiologist 1 year after the procedure. If
the radiologist observes a suspicious lesion on imaging at 1 year, a microbiopsy is
performed to establish a definitive diagnosis. In this indication, the information given
to the patient must be particularly thorough and extensive, with comprehensive
handouts provided during the preoperative consultations.
2285
Chapter 63  Fat Grafting to the Breast
The indications for breast augmentation with fat grafting (lipoaugmentation) differ
from those of implant augmentations. Lipoaugmentation is suitable for patients re-
questing a moderate or even slight increase of breast volume or who want to recover
the upper pole fullness they had before weight loss or pregnancy. The ideal patient is
a young woman with a slim upper body and moderately small breasts who has suf-
ficient localized adiposity of the lower body to allow one or even two lipomodeling
sessions. In such a patient, fat harvesting should enhance the lower body contour
and can be combined with standard liposuction to improve the final result. We en-
courage the patient to maintain a stable weight after this procedure, because any
change in weight might affect the shape of the breasts.

Revision After Implant Augmentation
Aesthetic lipomodeling is a treatment option for correction of the imperfections of im-
plant augmentation. It enhances the cleavage and décolleté area; improves tissue
coverage of the implant, especially in the lower pole; reduces rippling in thin pa-
tients; and reduces the demarcation of the implant in the upper pole. We also have the
clinical impression, though no scientific data as yet, that complementary fat graft-
ing might improve capsular contractures in moderate cases. We usually recommend
fat transfer with the previous implant still in place. After all deformities are cor-
rected, the implant is replaced; this avoids any risk of leaving a punctured implant.
Managing Severe Complications of Breast Aesthetic Surgery
With Residual Sequelae
Breast reduction, breast augmentation, and mastopexy are commonly performed
procedures in aesthetic breast surgery. The outcomes are usually satisfactory for the
patient and surgeon. In rare cases, complications occur. In thin patients who smoke,
exposure of an implant can result in the need to remove the implant. Reduction of
large breasts can result in fat and skin necrosis with subsequent breast deformity.
2286
Part XI  Breast Surgery
Some patients are referred to our clinic for revision and secondary procedures. We
find lipomodeling to be very useful in these cases. It efficiently enhances tissues thick-
ness and improves tissue quality.
After implant complications leading to implant removal, lipomodeling prepares the
tissues to render the secondary augmentation safer. After complicated breast reduc-
tions, fat transfer can restore the suppleness of the breast while improving the qual-
ity of the damaged skin.
These complementary fat grafting procedures have reduced donor site morbidity
while reducing the incidence of breast sequelae. We have also found lipomodeling
to be very useful in the management of difficult patients with high expectations who
may present a risk of medicolegal issues.

Preoperative Assessment
The patient’s weight should be stable at the time of the procedure, because the in-
jected fat will retain the characteristics of the fat deposits in the donor site. If the
patient loses weight after lipomodeling, she will lose some of the benefits of the
procedure.
The operative technique, its benefits, and potential risks and complications are thor-
oughly discussed with the patient, and she is provided with an informational hand-
out with an informed consent to sign. We have four handouts: lipomodeling in breast
reconstruction, lipomodeling to correct the sequelae of conservative treatment, lipo-
modeling to correct breast deformities, and aesthetic breast lipomodeling.
Preoperative Planning
Markings
The areas of the breast that require correction are identified and marked on the pa-
tient. In some patients we now perform a three-dimensional morphologic study, in
addition to the usual two-dimensional photographs; this provides further useful in-
formation for assessing the amount of fatty tissue to be transferred and evaluating
secondary fat resorption.
The various adipose areas of the body are examined to identify excess fat deposits.
Generally, we harvest fat from the abdomen, because harvesting in this area does
not require a change in the patient’s position during the procedure, and liposuction
in the region can lead to beneficial recontouring. The second site is the trochanteric
region (saddlebags) and the inside of the thighs and knees. The areas to be harvested
are outlined with a skin marker.
Operative Technique
Anesthesia
Because of the significant amounts of fat harvested, lipomodeling is performed with
the patient under general anesthesia in most cases. Conventional prophylactic an-
tibiotics are usually given perioperatively, as we customarily do in various plastic
surgery procedures. Local anesthesia can be used for minor revisions to correct any
residual defect.
2287
Chapter 63  Fat Grafting to the Breast

2288
Part XI  Breast Surgery
Incision Placement
In the harvest sites, incisions are made with a No. 15 blade. For abdominal harvest-
ing, four incisions are made around the umbilicus, and a lateral incision is made on
each side if lateral abdominal and suprailiac fat is to be harvested. For harvesting
from the thighs, the patient is placed in a ventral decubitus position, and an incision
is made in each subgluteal fold. A complementary incision on the inside of the knees
can be made for fat harvesting of this area.
At the recipient site on the breast, punctiform incisions are done with a 14-gauge
needle; it is ideal to hide these sites in previous scars. To create a network of trans-
fer tunnels, five or six incisions are needed, two of which are in the inframammary
fold and one in the décolleté area. The incisions are usually made with the sharp
bevel of a trocar.
Fat Harvesting
Recent published studies on fat transfer have contributed to standardization of the
procedure for harvesting and injection, thus reducing the potential pitfalls at each
stage. Meticulous technique throughout the process enhance fat survival in the short,
medium, and long term. A disposable or Coleman cannula is used for harvesting.
These cannulas have a blunt tip that can be inserted in a 4 mm incision made with
an No. 15 blade. Harvesting is done with a syringe. Subcutaneous infiltration is done
with 500 ml of a 9% normal saline solution and 0.5 mg of epinephrine. A 10 cc
Luer-Lok syringe is fitted directly onto the harvesting cannula.
Moderate suction will minimize damage to the fat cells; mechanical suction that is
too strong might have a harmful effect on adipocyte survival. More fat than has been
calculated for transfer must be harvested in anticipation of the separation resulting
from centrifugation and the expected resorption of fat in the breast after transfer.

Finally, to perfect the morphologic result, the harvested areas are smoothed with
conventional liposuction using a 4 mm cannula. The cutaneous incisions are closed
with fine, rapid-absorbing sutures.
Fat Preparation
2289
Chapter 63  Fat Grafting to the Breast
As harvesting continues, the assistant prepares the syringes for centrifugation. They
are sealed with a screw top and then centrifuged in batches of six for 1 minute at
3200 rpm. Centrifugation separates the harvested fat into three layers: a top layer
of oily fluid containing chylomicrons and triglycerides resulting from cell lysis; a
lower layer of blood, debris, and serum, as well as the infiltration fluid, especially if
the harvesting is done with a local anesthetic; and a middle layer of purified fat. This
is the useful layer that will be injected.
The other two layers are disposed of, the lower layer simply by removing the cap
and the upper layer by pouring off the oil the covers the middle layer. The team must
be well organized so that fat preparation is carried out efficiently and rapidly. With
a three-way tap, the purified lipoaspirate is grouped into 10 cc syringes by transfer
from one syringe to another, thus producing a sufficient quantity of 10 cc syringes
of purified fat.

Fat Transfer
2290
Part XI  Breast Surgery
After the fat has been prepared, the 10 cc syringes of fat are ready for transfer. The
fat is transferred directly to the breast areas with the 10 cc syringes fitted with spe-
cial disposable 2 mm transfer cannulas. These cannulas are longer and stronger than
the cannulas used for facial fat grafting procedures, because the recipient breast tis-
sue is firmer and more fibrous. The incisions are made using a 17-gauge trocar. This
produces an adequate incision while limiting scarring. Several incisions are made to
create a honeycomb of multiple microtunnels for fat transfer.
The fat is injected in 1.5 to 2 cc per pass in the form of fine cylinders resembling
spaghetti. Microtunnels must be created in many directions. Transfer is done from the
deep to the superficial layer. Good spatial visualization is necessary to form a three-
dimensional matrix and to avoid areas of fatty collections that would lead to fat
necrosis. Each microtunnel must be designed to be surrounded by well-vascularized
tissue. Fat is injected under light pressure as the cannula is gently withdrawn, not
during advancement of the cannula.
As noted, one must overestimate the quantity of fat transferred when possible, an-
ticipating a 30% expected fat resorption. A 140% rule must be applied, meaning
that 140 cc of fat must be injected for a desired final volume of 100 cc.

When the recipient tissues are saturated and cannot absorb more fat, it is useless
to persist because of the risk of inducing areas of fat necrosis. Oversaturation of
the recipient site with fat grafts must be avoided. Planning a supplementary session
in a few months is preferable and leads to more stable results. Very fine, rapid-
absorbing sutures are placed, and the breast is covered with an ordinary dry dress-
ing for a few days.
Ancillary Procedures to Improve Results
Liposuction of the Inframammary Fold
In patients with a bulky inframammary area anterior to the inferior ribs, we per-
form a heavy liposuction of the area (7 to 8 cm under the inframammary fold). This
liposuction enhances the projection of the breast and lends inframammary defini-
tion while giving the impression of a complementary breast augmentation.
We use this method in major breast reduction procedures in overweight patients to
improve the definition of the breast. It can also be used in tuberous breasts and in
lipomodeling-only breast augmentation to improve the final outcome.
The technique consists of significant liposuction, going from the deep to the super-
ficial layers of the skin in the predefined area while restoring the inverted V result-
ing from the junction of the two inframammary folds and the intermammary val-
ley. Because liposuction in this area is painful, we infiltrate dilute ropivacaine at the
end of the procedure.
Inframammary Fold Definition
In some cases of aesthetic breast surgery, the inframammary fold is ill defined or has
been damaged by previous surgery. A push-up bra will enhance the fullness of the
upper pole by displacing the mammary gland to the upper region, simultaneously
displacing the necessary amount of tissue to define the inframammary fold from the
lower pole.
We consider the inframammary fold to be the foundation of the breast. To create or
re-create the inframammary fold (see p. 2303), we use a technique derived from our
reconstructive experience in cases of latissimus dorsi reconstruction with a low-
situated inframammary fold.
We locate the desired level of the inframammary fold and draw a horizontal mark-
ing on the midclavicular line. We mark a horizontal ellipse under this desired infra-
mammary fold (5 to 6 cm wide and 2 to 3 cm high). The ellipse is deepithelialized
and the upper border of the ellipse is incised to the thoracic wall with cautery.
2291
Chapter 63  Fat Grafting to the Breast

The deepithelialized flap is kept attached to the thoracic skin while the deep plane
is undermined for 5 to 6 cm. This deepithelialized flap is pulled up under the breast
and sutured to the thoracic wall with 1 Vicryl at the predefined position of the in-
framammary fold. The lower pole of the breast is undermined at the level of the pec-
toralis muscle, then rolled to define the lower pole contour and sutured to the fixed
inframammary fold.
The disadvantage of this technique is the resulting 6 cm scar, but this can usually be
hidden in the inframammary fold. The main advantage is the enhancement and effi-
cient correction of the inframammary fold.
In the rare cases in which this technique is used for lipomodeling augmentation of
the breast, we start by fixating the inframammary fold, then we do the fat transfer.
Release of Fibrous Strings and Adhesions
While transferring fat to the breasts, the surgeon sometimes encounters fibrous strings
or adhesion areas, making lipomodeling difficult. The inferomedial area in tuberous
breasts is a typical example. In such cases we recommend the use of V-shaped trans-
fer cannulas or the tip of a 14-gauge trocar to selectively rupture these strings and
adhesions under local tension. Care must be taken not to undermine the area, be-
cause the transferred fat will not take if it is not in proper contact with a vascular
recipient site.
External Expansion of the Breast
External expansion of the breast with the Brava breast enhancement and shaping
system (Brava, Coconut Grove, FL) was developed by Roger Khouri in the 1990s
for breast augmentation without surgery. A gentle three-dimensional vacuum is ap-
plied via two silicone domes that place the breast under tension. The expected out-
come is breast tissue augmentation, given strict adherence to the protocol, which
means that the device must be worn 10 hours a day for 10 weeks. The use of the
system alone did not lead to significant volume enhancement because of the con-
straint of wearing the Brava bra daily for an extended time.
With the recent development of fat grafting to the breasts, Dr. Khouri decided to
combine fat grafting with the Brava system. The external expansion is used for the
preparation and optimization of the recipient site. The concept behind this is to in-
crease the initial breast volume so larger amounts of fat can be transferred to the
breasts. External tissue expansion might also enhance the vascular supply to the
breast and thus improve graft take.
At present, we are evaluating the Brava system in conjunction with our lipomodel-
ing procedures. Our preliminary experience shows that we are able to transfer larger
amounts of fat in one lipomodeling session as compared with the traditional tech-
2292
Part XI  Breast Surgery

nique. Our second impression is that there is improvement in areolar projection with
the combined use of the Brava system and lipomodeling.
The external expansion system might change the surgical indications in cases of se-
vere Poland’s syndrome and breast reconstruction with fat transfer only. It might
even eliminate the need for flap reconstruction in some cases. A study is underway
in our department to determine more precisely the advantages of the Brava system
and its indications.
Processed Fat Grafting With Enrichment Procedures
Fatty tissue is rich in adipose-derived stem cells at different levels of differentiation
with multiple progenitors. It has been proposed to modify the composition of the
fat transferred by enriching it with adipose-derived stem cells. The protocol consists
of harvesting the fat, then processing it in the Celution system (Celution System, San
Diego, CA), which will release concentrated stromal cells. These stromal cells are
mixed with the fat harvested before its transfer to improve the take of the graft.
Studies are underway in Europe and Asia to determine the efficacy of this system.
At present the system has not yet obtained FDA approval in the United States or
AFSAPS approval in France.
Postoperative Care
Harvest Sites
Pain in the harvested areas is similar to the pain after liposuction. Patients complain
of moderate pain that typically lasts 48 hours; this can be treated with level 1 anal-
gesics, prescribed for 2 weeks. We infiltrate dilute ropivacaine at the end of harvest-
ing to control pain during the first 24 hours. At the end of the procedure, a com-
pressive elastic dressing is left in place for 5 days.
Considerable bruising occurs in the harvest sites and persists for 2 weeks. Postop-
erative edema resolves totally or almost totally in 3 months. To hasten resorption,
we ask patients to massage the harvest sites with a circular motion. An abdominal
support belt may be advisable for 6 weeks but is not prescribed routinely. In rare
cases, if edema persists, we advise 10 sessions of endermologie drainage.
Breast
Bruising resolves in 2 weeks, edema in 1 month. During the first 3 postoperative
months, 30% to 40% of the added volume is gradually lost. But because of the ini-
tial edema, the patient may have the impression that she has lost about 50% of her
breast volume, because she saw the breast the day after the procedure, when the
breast was the most swollen.
2293
Chapter 63  Fat Grafting to the Breast

Complications
At the harvest site, scars must be concealed as much as possible, generally in a fold or
in the periumbilical region. No patients have complained of unaesthetic scars in a
donor site. We had one case of irregularity in the suprailiac region that required sec-
ondary correction by lipomodeling. The majority of patients are satisfied with the
slimming of the donor site; this additional benefit probably contributes to the very
high rate of satisfaction with this technique. Irregularities at the donor site may be
caused by uneven harvesting of the fat grafts, so harvesting is sometimes completed
by liposuction to further improve the result and for greater patient satisfaction.
This procedure must be carried out by experienced plastic surgeons who have com-
pleted their learning curve, because previous experience with cosmetic liposuction
is essential in these circumstances to limit the risk of complications and to produce
the best possible cosmetic result.
Local infection occurred in only 1 of our 950 lipomodeling procedures. This was
seen as redness around the umbilicus and was treated with antibiotics and local ap-
plication of ice, with no long-term sequelae.
In the breast the incisions must be well placed, in the submammary fold or in its ax-
illary tail, or in the areolar region, where scars are always of good quality. The prester-
nal area should be avoided because there is and increased risk of hypertrophic scar-
ring, seen as small, red, hypertrophic, punctate scars. The incisions are usually
invisible: because they are made with a trocar, they measure only 1.5 mm.
Infections occurred at the recipient site in 6 of our 950 lipomodeling patients. Red-
ness at the recipient site was seen, and sutures were removed. An effusion of fat and
pus was evacuated. Topical treatment, antibiotics, and applications of ice completely
resolved the problem in each case, with no impact on the final results.
We had one case of intraoperative pneumothorax in 950 procedures, probably as a
result of the transfer cannula piercing the pleura. The pneumothorax was revealed
by oxygen desaturation during the procedure. In the recovery room, a pleural drain
was inserted, and oxygen saturation returned to normal, with total recovery and no
sequelae. To avoid this complication, the projection of the areolar region should be
improved through two incisions in the submammary fold, not through the areolar
region itself.
There were no instances of fat embolism in our series. There is a potential risk of
this if fat is injected into a large vessel. Extreme caution is recommended in the sub-
clavian area, especially in the breast and chest wall deformities of Poland’s syndrome,
where the subclavian vessels may lie lower than in a patient with normal anatomy.
2294
Part XI  Breast Surgery

In 3% of cases we observed focal fat necrosis. The risk is higher during a surgeon’s
early experience (15% in the first 50 cases). In these cases, fat necrosis occurred in ar-
eas overtreated and oversaturated with fat; the recipient site could not absorb the
amount of fat grafted. When the recipient tissue is saturated with fat, the surgeon
should not persist, because areas of fat necrosis may develop. Clinical signs of fat
necrosis are typical: tender, slightly sensitive but stable over time, then gradually de-
creasing. Any increase in the size of a hard swelling, even in a reconstructed breast,
should signal the need for microbiopsy by a radiologist to rule out a malignant
change.
Fat necrosis nodules are mainly seen in the early stages of the surgeon’s learning
curve and decrease as experience increases, if he or she respects the principle of the
three-dimensional injection network and avoids oversaturation of the recipient site.
Outcomes and Long-Term Follow-Up
Based on the first author’s (E.D.) personal experience of 880 procedures of recon-
structive and aesthetic breast surgery, and with a 10-year follow-up for the first pa-
tients, reliable indications on long-term follow-up can be stated.
Clinical
All patients were clinically followed and seen in consultation after 15 days, 3 months,
and 1 year. Photographs were taken at each visit. A detailed follow-up protocol was
used to assess the quality of the result from the patient’s and surgeon’s viewpoint,
to document patient satisfaction, and to note any adverse effects or complications.
The results were considered very good or good in the majority of cases. Very few re-
sults were considered to be moderately good, and none was evaluated as poor. The
percentage of good or very good results depends on the subpopulation studied in
relation to the indications. For example, for correction by lipomodeling of sequelae
of breast-conserving therapy, 50% were considered very good, 40% good, and 10%
moderately good.
Patients who had had breast cancer and underwent a lipomodeling procedure after
breast-conserving therapy or breast reconstruction were then followed by their on-
cologist, who referred them to us if there was any change in the follow-up clinical
and imaging findings. For the other patients, computerized medical records were
shared among the radiologist, oncologist, breast surgeons, and plastic surgeons to
complete the long-term follow-up.
2295
Chapter 63  Fat Grafting to the Breast

Radiologic
In 1998, when we developed this area of research, the main fear concerning fat trans-
fer in the breast was the risk that it would compromise imaging studies. This fear
had in fact led to the earlier described controversy of 1987 and its consequences.
For this reason, we undertook analysis of the effect of fat transfer on breast imag-
ing. We carried out three studies with imaging of breasts reconstructed by autolo-
gous latissimus dorsi flaps and lipomodeling (mammography, ultrasonography, and
MRI), imaging of breasts treated with breast-conserving surgery after lipomodeling
(mammography, ultrasonography, and MRI), and imaging of breasts with defects
corrected by lipomodeling (asymmetry, tuberous breasts, and Poland’s syndrome)
(in process).
Our findings showed that if lipomodeling is carried out according to modern stan-
dardized principles, it does not hinder correct breast imaging and follow-up. It is
noteworthy that all procedures were performed by a surgical team that has com-
pleted its learning curve and with specialized radiologists who are familiar with the
analysis of image findings potentially induced by fat transfer. These prerequisites are
of fundamental importance for successful fat transfer in aesthetic breast surgery.
Imaging in the majority of reconstructed breasts yielded normal results, with some
images of oily cysts and fat necrosis. Any abnormal findings observed indicated
benign lesions, easily distinguished from suspicious lesions. Abnormal images were
essentially oily cysts, occurring in 15% of cases.
The most complex situation concerned lipomodeling for the sequelae of conserva-
tive partial mastectomy. In this population fat necrosis develops in about 20% of
patients postoperatively; lipomodeling doubles this incidence, generating mainly oily
cysts but sometimes more complex lesions of fat necrosis.
Because of the spontaneous local carcinoma recurrence rate of 1.5% per year,
follow-up must be rigorous. We believe that this indication should be restricted to
multidisciplinary teams working with radiologists who have excellent mastery of
the subject.
Oncologic
Ten years of oncologic follow-up have not revealed an increased risk of local re-
currence after mastectomy or after conservative treatment. In fact, the clinical im-
pression seems to be to the contrary. But to confirm this clinical impression, more-
complex oncologic studies must be performed that match treated populations with
reference populations with the same oncologic status.
2296
Part XI  Breast Surgery

Evaluation of the Success Rate
Clinical Evaluation
The success rate of fat transfer is easy to evaluate by clinical examination, the pa-
tient’s opinion, and comparison of the photographs taken at each consultation with
earlier photographs. Of the volume initially obtained through fat transfer, 30% to
40% is gradually lost. Volume is stable after 3 to 4 months and remains so if the pa-
tient maintains her weight. If the harvested fat is very oily (retains a very high percent-
age of oil after centrifugation), resorption may be higher (up to 40% to 50%) and
may continue over a longer period (5 to 6 months).
If the patient loses weight, the volume of the transferred fat decreases, and the re-
sult is a smaller breast with possible asymmetry. Therefore it is important for the
patient to understand that she must maintain a stable weight. Inversely, if she gains
weight, breast volume increases.
When a second fat transfer session is performed to produce sufficient volume, re-
sorption seems to be less, between 20% and 30%.
Very long–term evaluation (5 to 6 years) confirms that breast volume remains sta-
ble. If asymmetry appears after weight loss or gain (for example, after discontinua-
tion of antihormonal treatments in adjuvant therapy for breast cancer), a comple-
mentary lipomodeling session can easily be performed. This technique offers flexibility
and precision for a long-lasting revision that is appreciated by the patients.
Evaluation by Interferometry
Using three-dimensional interferometry technology, we studied changes in breasts
over time after lipomodeling. The technique consists of light projection and reflection
over three-dimensional structures (in this case, the fat grafted breasts). The reflected
light is processed using modeling algorithms. This produces a three-dimensional rep-
resentation of the breasts from which measurement of distance and volumes can be
calculated. By comparing the models of the breast, breast volume can be accurately
studied and the quantity of fat remaining after resorption can be assessed. This study
confirmed our clinical impression: the rate of fat absorption at 3 months was esti-
mated to be 30% to 40%. It also confirmed that volume remains stable after this
period if the patient maintains a constant weight.
2297
Chapter 63  Fat Grafting to the Breast

2298
Part XI  Breast Surgery
Results
This 17-year-old patient with Poland’s syndrome was treated with two sessions of
lipomodeling (205 cc, 297 cc) at an interval of 6 months. She is shown 1 year after
the second procedure.

This 17-year-old patient with lateralized pectus excavatum was treated with two
lipomodeling sessions of the right breast (200 cc, 360 cc). She is shown 1 year after
the second procedure.
2299
Chapter 63  Fat Grafting to the Breast

This 27-year-old patient with tuberous breasts was treated with two lipomodeling
sessions of the left breast (209 cc, 179 cc), and right mastopexy and lipomodeling
(100 cc). Her result 30 months after the second procedure is shown. The patient had
a pregnancy before the final result without affecting the results.
2300
Part XI  Breast Surgery

This 22-year-old woman had marked asymmetry (unilateral hypoplasia). She was
treated with one lipomodeling session of the left breast (250 cc). One year after the
procedure, she is shown with improved symmetry and correction of her hypoplasia.
2301
Chapter 63  Fat Grafting to the Breast

This 38-year-old woman had bilateral breast augmentation with one lipomodeling
session (left breast 235 cc, right breast 220 cc). She is shown 15 days and 1 year
postoperatively.
2302
Part XI  Breast Surgery

This 48-year-old patient was seen as a secondary case with severe sequelae after fail-
ure of many breast implant augmentations, and further mastopexy. She was treated
with one lipomodeling session (left breast 250 cc, right breast 280 cc) and infra-
mammary fold fixation. The flap was marked, then incised and deepithelialized. In-
cision of the upper part of the flap is shown, and finally flap fixation to the thoracic
wall. Three months after the procedure, the restored inframammary fold is evident;
a second session of lipomodeling is scheduled.
2303
Chapter 63  Fat Grafting to the Breast

Concluding Thoughts
Lipomodeling is a major development in reconstructive and aesthetic surgery of the
breast; we consider it to be one of the major advances of the past 20 years. The tech-
nique is now well codified, and the associated complication rate is very low. Clini-
cal long-term follow-up shows that the morphologic result regarding volume is sta-
ble 3 to 4 months after the procedure. The development of focal fat necrosis is
strongly operator dependent, occurring in 15% of cases in the surgeon’s early expe-
rience and becoming stable at 3% after more experience. The radiologic appearance
of the breasts is usually normal, sometimes with images of fat necrosis seen as oily
cysts, or more rarely, calcifications or complex cysts. None of these images is likely
to be confused with a diagnosis of cancer for radiologists who are experienced in
breast imaging. If there is the slightest doubt, the next step must always be micro-
biopsy of the suspect area to obtain a definitive diagnosis. Oncologic follow-up (now
10 years for our first patients) shows no increased risk of local recurrence or of de-
velopment of a new cancer.
Evaluation of the success rate by clinical examination and by interferometry shows
that 30% to 40% of the injected fat is resorbed. The final volume is reached in 3 to
4 months and is stable over time if the patient maintains a constant weight. If a sec-
ond fat transfer session is performed, resorption will be somewhat less, usually be-
tween 20% and 30%.
Because of the low complication rate, the very good results obtained, and the excel-
lent acceptance of the technique by patients, lipomodeling has completely modified
our indications in plastic, reconstructive, and aesthetic surgery of the breast.
The use of lipomodeling to correct deformities of the chest wall and breast is rap-
idly being adopted. For the treatment of Poland’s syndrome, lipomodeling appears to
represent a major advance and will probably revolutionize the treatment of severe
cases, producing reconstruction of unequaled quality after fat transfer procedures
with a simple postoperative course and little scarring. Lipomodeling can also cor-
rect the breast and chest wall deformities associated with some cases of lateral pec-
tus excavatum and is a useful adjunct to custom-made implants for more severe
forms of pectus excavatum. It is a promising alternative treatment for tuberous
breasts and implant-free correction of asymmetry caused by unilateral hypoplasia.
Finally, the applications of lipomodeling will no doubt continue to develop in aes-
thetic surgery for the correction of inadequate mammaplasty, correction of defects
or complications of implants, and in lipoaugmentation for patients desiring moder-
ate, natural breast enhancement and who have sufficient adipose deposits. Preoper-
ative and postoperative imaging by a radiologist who specializes in breast imaging
is essential to limit the risk that a cancer may occur coincident with lipomodeling.
2304
Part XI  Breast Surgery

Clinical Caveats
 Careful preoperative clinical and radiologic assessment and clearance for the pro-
cedure are essential before a fat transfer procedure.
 Fat must be injected in a multilayered fashion, starting from the deep plane and
moving to the superficial plane.
 Fat must be injected in fine tunnels in a consistent fashion to avoid fat necrosis.
 Fat transfer should be stopped at each injection site when the recipient site is sat-
urated.
 Resorption rates, the quality of the fat transferred, and characteristics of the re-
cipient site must be taken into account in initially overcorrecting volumes to pro-
duce the desired contour and volume.
2305
Chapter 63  Fat Grafting to the Breast
Annotated Bibliography
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This was the first detailed presentation of fat transfer to the native breast, harvested with
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Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic
Plast Surg 19:421-425, 1995.
The author presents a clinical study of the long-term survival of fat transferred to the
face with the initial rate of resorption, then a stable result, compared with a noninjected
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Delay E, Delaporte T, Sinna R. [Breast implant alternatives] Ann Chir Plast Esthet 50:652-672,
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A review of the current alternatives to breast implants, mainly the autologous ones. Pedi-
cle flaps and free flaps are presented. Fat grafting is described, and its indications in aes-
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Delay E, Garson S, Toussoun G, et al. Fat injection to the breast: techniques, results and in-
dications based on 880 procedures over 10 years. Aesthet Surg J 29:360-376, 2009.
A single-operator, large retrospective study of fat injection to the breast in its different
indications: reconstructive and aesthetic. Techniques, expected results, and the neces-
sary follow-up of patients are discussed.

Delay E, Sinna R, Delaporte T, et al. Patient information before aesthetic lipomodeling
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Brown FE, Sargent SK, Cohen SR, et al. Mammographic changes following reduction
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Part XI  Breast Surgery

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Breast Augmentation With External
Expansion and Megavolume
Autologous Fat Grafting

ROGER K. KHOURI, DANIEL A. DEL VECCHIO
CHAPTER 64

I
n aesthetic plastic surgery no topic stirs as much excitement, curiosity, and on-
going controversy as fat grafting to the breasts. Despite the increased popularity of
the procedure, many unanswered questions remain, and there is an unmet clinical
need for standardization of the process and for understanding the physiology and
true fate of transplanted fat. In 2009 the American Society of Plastic Surgeons (ASPS)
modified their previous position against fat grafting to the breasts, thus paving the
way for more investigation into this procedure. Today many surgeons realize that
with optimal technique, fat grafts to the breast survive indefinitely, and further, that
the radiographic arguments behind the previously imposed ban are no longer valid,
so many investigators around the world have begun sharing their previously un-
published experience with fat grafting to the breast.
Fat grafting is a powerful tool for filling and reshaping body contours. When this
technique is combined with external expansion, it offers a viable option for breast
augmentation and treatment of breast asymmetries. The key to this technique is prepa-
ration of the breast with preexpansion, controlled low-pressure graft harvesting, and
infiltration of autologous fat through multiple needle puncture sites, with diffuse
grafting in a three-dimensional fanning-weave pattern.
In this chapter we describe our rationale for external breast expansion with the Brava
expansion system combined with megavolume fat grafting based on our clinical ex-
perience with more than 100 breast augmentation procedures, which have produced
consistent results comparable to those achieved with implant augmentation (as doc-
umented by MR imaging and three-dimensional volumetric determination). We pro-
vide information on indications and patient selection criteria and outline our tech-
niques and the results that may be expected when this combined technique is used
for breast augmentation.
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Part XI  Breast Surgery

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Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
Background
OFF
ON
The Brava external tissue expander
The Brava bra (Brava, Coconut Grove, FL) was initially developed in the 1990s as
an external soft tissue Ilizarov expander to enlarge the breast. The device consists of
a pair of semirigid domes with a silicone gel rim cushion that interfaces with the
skin; it is worn around the breasts like a bra. A small, concealed, battery-operated
pump maintains a low negative pressure inside the domes that does not interrupt
capillary flow and that imparts on the breast surface a constant gentle isotropic dis-
traction force. Studies have shown that when the device is worn in an uninterrupted
fashion for 10 to 12 hours per day, true and long-lasting breast augmentation ensues
over a period of weeks to months.
Combining a regimen of Brava external expansion with structural fat grafting can
predictably yield a 200 to 300 cc breast augmentation per grafting session. For ad-
equate expansion it is recommended that the Brava domes be worn at least 10 to
12 hours per day for a minimum of 4 weeks. Although the smaller domes can be
concealed under loose clothing, most women prefer to wear the bra at home and to
sleep with it on. Adequate expansion is attained when the breasts are estimated to
have enlarged threefold to fourfold in volume. The better the preoperative expansion,
the more fat that can successfully be grafted, and thus the larger the augmentation.
Indications for External Expansion
With Megavolume Fat Grafting
Women with excess fat in the lower body and a fat deficiency in the breasts are ob-
vious candidates for external expansion combined with fat grafting to the breasts.
However, some of the most impressive results are seen in very small–breasted women
(less than 100 cc), in whom a 200 cc breast augmentation can make a real differ-

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Part XI  Breast Surgery
ence, compared with women who already have breasts of 500 cc or more. This pro-
cedure is reserved for an informed patient who understands the concept of fat graft-
ing and accepts responsibility for her result by adhering to the expansion protocol.
The best candidates for this technique:
1. Have favorable anatomy (donor fat, breast anatomy)
2. Do not have active detectable breast cancer (although the test has poor speci-
ficity, we recommend a preoperative MRI as the most sensitive test for any
breast abnormality)
3. Have realistic expectations (a cup size increase)
4. Are reliable (can comply with the Brava regimen)
5. Are nonsmokers (smoking is an absolute contraindication)
Patient Profiles
Women After Childbearing With Preexpanded Breasts
Anatomically speaking, an ideal patient for Brava preexpansion and megavolume fat
grafting is a patient who has had one or more children, has breast deflation but not
frank ptosis, and has an adequate amount of donor fat. Patients who have had chil-
dren have already undergone one or more episodes of parenchymal expansion from
engorgement with breast milk. Engorgement creates a natural stretching and loos-
ening of the parenchymal ligaments. Although this may have occurred years before
the Brava expansion, this prior stretching of breast tissues allows an easier, more
rapid expansion when Brava is applied, given the same degree of negative pressure
and time used.
Often the breast deflation seen in multiparous patients is low-grade ptosis or pseudop-
tosis. Patients with frank ptosis who require a breast lift can also benefit from ex-
ternal expansion, but the timing of the mastopexy surgery is best performed at the
completion of the grafting process.

Women With Small Breasts
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Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
Thin patients with small breasts often do not want a major volume increase; there-
fore even thin patients may be candidates for Brava preexpansion with fat grafting, as
long as realistic expectations are discussed preoperatively. Smaller breasts, even if
doubled in volume, are still not very large.
Women With Small, Dense Breasts
Breasts with dense parenchyma will expand with more difficulty than the soft breasts
of a multiparous woman. Patients with dense-parenchyma breasts must be coached
effectively to increase the negative pressure on the domes to achieve adequate pre-
operative expansion. Often the dense parenchymal breast will expand more in some
areas, such as the periareolar region, than in others. This can result in a double-bubble
constriction deformity that must be released at the time of surgery.
After expansion, there is a step-off deformity at the breast-areolar junction as a result
of the lower resistance of the areolar tissue compared with the breast tissue. The
problem can be seen in this patient, who will require three-dimensional mesh release
intraoperatively to address this deformity.

Women With Constricted or Tuberous Breasts
Constricted or tuberous breasts require aggressive expansion, and following this the
constrictions can be released mechanically using the “Rigottomy” three-dimensional
mesh release technique (see p. 2334).
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Part XI  Breast Surgery
This patient is shown before and after expansion with the Brava system; no fat graft-
ing has been done yet. She will require aggressive release of the inferior mammary
fold using a three-dimensional mesh release Rigottomy technique at the time of fat
grafting. Postoperative expansion is also often required for constricted breasts.
Patient Evaluation
Similar to the regimen for breast augmentation with implants, we think it is impor-
tant to obtain a baseline evaluation of the recipient breasts before any intervention is
planned. Our routine protocol calls for a baseline MRI for all women requesting
augmentation with fat grafting. In young women with dense breasts, this is the most
sensitive test. It also provides a three-dimensional image analysis of the breasts that
is unattainable with conventional biplanar mammography.
Patients should also be evaluated for associated medical conditions that might oth-
erwise exclude them from safely undergoing a liposuction procedure. We believe this
is the aspect of the intervention that probably produces higher morbidity than breast
fat grafting. Smokers, with their impaired microcirculation, are not candidates for
fat grafting. Potential fat donor sites are evaluated for their availability.
Constricted breasts, before and after expansion (and before fat grafting)

Patient Selection and Education
Compliance
There are two critical areas of compliance: the patient’s tissue and the patient. The
mechanical compliance of the breast tissue is an important consideration in effec-
tive preexpansion and fat grafting. A properly motivated patient is vital for the suc-
cess of preexpansion, which in turn is vital for the success of the fat grafting proce-
dure. The surgeon and patient must be equally committed to the preexpansion process
to achieve a successful result.
No Expansion—No Surgery
Despite adequate screening for compliant behavior, some patients who initially in-
tend to proceed with Brava preexpansion and grafting will simply fail to expand. In
these patients, fat grafting is not performed until satisfactory expansion is obtained.
It is far better to postpone a procedure after a failed expansion than it is to move for-
ward and perform what may result in a failed operation. Without adequate preex-
pansion, the results of fat grafting to the breast may be limited to small graft vol-
umes (100 cc or less) that do not exceed high interstitial pressures in the recipient
site. In breast augmentation, such volumes are rarely adequate to achieve core tissue
projection replacement. Therefore, if a surgeon performs grafting on a patient whose
breasts have failed to expand, it is likely that repeat procedures will be necessary. In-
evitably, this will be interpreted as a failure of the procedure, resulting in the need
for repeat procedures, a dissatisfied patient, or both.
Classification of Breast Morphologies
Based on our experience with diverse breast types, we have developed a hierarchy of
preoperative breast morphologies, as shown in the table.
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Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
Preoperative Classification of Brava Breast Morphology
Type
Description of Breasts
Sessions
I
Multiparous, soft
1
II
Nulliparous, dense
1-2
III
Constricted or tuberous
2
IV
Mastectomy, nonirradiated
1-4
V
Mastectomy, irradiated
3-5

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Part XI  Breast Surgery
This classification takes into account the compliance of the patient’s parenchymal
tissue and the starting volume of tissue available for expansion. With this information
one can advise patients about the effort required for the expansion and the realistic
number of sessions required to achieve the desired result.
Patient education is crucial in ensuring adequate compliance with the expansion reg-
imen. We show the patients pictures of the expected expansion effect and explain
that the more their breasts are expanded and the larger they are at the time of graft-
ing, the more grafts we can inject and the larger their breasts will be. An educated,
informed patient then becomes a full participant in achieving her result. We plan an
office visit a week or so before surgery to confirm patient compliance and to ensure
adequate expansion. On occasion, we have postponed the surgery to allow more ex-
pansion time.
We believe there is no substitute for sufficient preexpansion. Last minute “cramming”
by the patient does not result in successful preparation. It is ultimately the respon-
sibility of the surgeon to adequately select, educate, coach, and follow up with pa-
tients to ensure that optimal preexpansion is attained.
Preoperative Planning
Fat Harvesting and Processing
A vast amount of literature has been written on the preparation and harvesting of
fat. Unfortunately, there is little that is definitive and not subject to dispute. We pre -
sent our preferred techniques and biases.
Overview of Megavolume Fat Grafting
Conceptually, megavolume fat grafting can be compared with sowing seeds in a three-
dimensional field. Four critical components need to be optimized to maximize the poten-
tial for producing a high-yield crop:
1. Seeds: Fat harvesting and processing
2. The field: Preparation of the recipient breast: this remains the main limiting factor
3. Planting: Grafting technique
4. Nurturing the planted seed: Care of the breast after grafting

Harvesting Pressure
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Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
While a standard liposuction machine can generate up to 1 atmosphere (atm) (760
mm Hg) of negative pressure, a 60 cc syringe connected to an inline manometer can
also generate nearly 1 atm of negative pressure. The adipocyte is impartial to the
source of negative pressure; it is the absolute pressure and not the source of this pres-
sure that makes a difference in adipocyte trauma. It is well recognized that at pres-
sures higher than 0.5 atm there is adipocyte damage. Thus there are two alternatives:
either use a liposuction aspirator where the pressure can be dialed to approximately
300 mm Hg (12 inches Hg), or use a syringe system that maintains the pressure at
about 300 mm Hg (KVAC). The former is readily available in most operating rooms
but has the drawback of increased air exposure, with the potential for fat desicca-
tion in the long tubing. The latter provides a gentler closed system with less fat loss.
We use both techniques and when the fat is scarce and precious, the closed system
is preferable, whereas in patients with ample fat, there is probably no difference.
A completely closed technique for fat harvesting and grafting is performed with the
Lipografter (Lipocosm, Key Biscayne, FL). This KVAC spring-activated syringe as-
pirates the fat at a constant 300 mm Hg pressure throughout the excursion of the
plunger. When the syringe is full, pushing the plunger down cocks up the spring for
the next cycle of suction and sends the lipoaspirate through a nonclogging tissue
valve to a bag where the fat is prepared for reinjection using the tissue valve in re-
verse mode. The system allows rapid harvesting and processing of larger lipoaspirate
volumes; the controlled low pressure harvesting with no air exposure is thought to
be safer for adipocytes.

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Part XI  Breast Surgery
Cannula Size
Smaller cannula sizes theoretically create less donor site trauma and allow removal of
smaller lobules of fat, which may revascularize more easily, improve flow character-
istics, and reduce trauma during reinjection. An important consideration besides can-
nula size is cannula hole size and the number of holes. A 12-gauge cannula with
6 to 8 side holes 2 by 1 mm in size can extract a significant amount of fat despite the
small caliber. The total surface area of individual openings on a 12-gauge, 12-hole
cannula approaches or exceeds the hole size of the classic 10 mm one-hole cannula
used in the 1980s, and produces much less donor area trauma. Further, each hole
selects for lobules of uniform small size, which are more likely to flow easily through
the injection cannula during the grafting phase of the procedure without the need
for further processing.
We have found that increasing the number of holes in
the cannula while amply compensating for the lower
vacuum force improves harvesting efficiency. Our pre-
ferred cannula is 12-gauge (2.7 mm), with 9 to 12 side
holes of 1 by 2 mm each.
We have found that a 6- to 12-hole cannula operating at 0.33 atm is just as efficient
in harvesting fat as a single-hole cannula operating at 1 atm of pressure.
Pressure (mm Hg)
1 atm
750
25
20
15
10
5
0
0.5 atm
375
0.33 atm
250
0.25 atm
175
1 hole
3 holes
6 holes
9 holes
12 holes
No. of cc per 10 strokes
Varying Negative Pressure and the Number of Cannula Holes