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

Although centrifugation can process highly concentrated fat, there are six potential
problems with centrifugation:
1. Adipocytes may be damaged by the high G forces.
2. It is a time- and labor-consuming process.
3. Adipocytes trapped in the concentrated centrifuged paste have less recipient
contact and ability to engraft than loosely dispersed adipocytes.
4. There is increased risk of overgrafting with a concentrated paste.
5. The flow of the pastelike graft is more difficult during reinjection.
6. There is a loss of beneficial growth factors, platelets, and other components
present in the gross lipoaspirate.
Concentrating adipocyte stem cells and remixing them with mature adipocytes to
increase cell viability is an exciting prospect. The theoretical benefit of a stem cell–
enriched graft is that the stem cells promote neovascularization to the recipient site,
improving yields. Although this may be an effective strategy in the future, there is no
evidence today that it provides a worthwhile advantage over conventional fat graft-
ing. Washing harvested graft with cell preservatives that stabilize the cell membrane
and repair “holes” resulting from trauma has recently been described and may have
a role in improving percent yields. We do not employ these techniques, since they are
not currently FDA approved.
One of the most confusing metrics in fat grafting is a lack of standardization when
one discusses percent yields. Once fat is lipoaspirated as a donor graft, there is an
infinite number of different concentrations of adipocyte volume relative to non -
adipocyte volume (blood, serum, crystalloid solution) that can be reached before
grafting the recipient site. Unless the concentration of adipocytes in the grafted ma-
terial can be accurately measured and unless the process of fat concentration is stan-
dardized, one cannot reliably measure the percent of grafted adipocyte volume that
survived grafting.
The Recipient Site in Fat Grafting
Compared to the attention devoted to graft material and its preparation, the role of
the recipient site has been largely neglected in the literature. To better appreciate the
role of the recipient site in fat grafting, consider the historical advances of fat graft-
ing compared with those of skin grafting. From descriptions in Sanskrit, small skin
grafts were taken by Hindus in 3000 BC after preparing the donor area (usually by
beating the patient’s backside) to increase edema and dermal thickness. Several thou-
sand years later, improvements in instrumentation afforded more-uniform donor
thicknesses. During the past 60 years in the post–World War II era, a combination
of more advanced wound care and debridement, antibiotics, and methods of graft
immobilization have helped to improve graft take. The introduction of the vacuum-
2320
Part XI  Breast Surgery

assisted closure (VAC) method has further revolutionized skin grafting by a variety
of postulated effects, including bacterial clearance, neovascularization, and reduc-
tion in edema of the wound bed.
Parallels Between External Expansion and Vacuum-Assisted Closure
Negative pressure on the breast creates internal expansion of the breast parenchyma
by drawing in more fluid and increasing the size and caliber of blood vessels.
2321
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
This patient is shown before and 3 weeks after Brava expansion, immediately before
grafting. The volumetric increase is three to four times that of the preexpansion state.
A total of 380 cc of fat was injected into each breast.
This MRI of the breasts of this patient demonstrates the contrast in her breasts be-
fore and 3 weeks after use of the Brava preexpansion bra 10 hours per day. As can
be seen, there is significant expansion of the breasts, with the creation of a larger
and more fertile recipient matrix that will allow more fat grafts to be placed. There
is an evident increase in the number and size of blood vessels.

2322
Part XI  Breast Surgery
We postulate that the external expansion process enhances fat grafting results in five
ways:
1. Bigger potential spaces are available for larger graft volumes.
2. Reduces demand on adipocytes to create the expansion, which may destroy
them.
3. Augments tension on internal constrictions and scars, so breast shape can be
addressed.
4. Variables that are time consuming (such as centrifugation) become less de-
manding.
5. Angiogenesis effect may increase recipient site capillary density and oxygen
tension and improve graft take.
The increased parenchymal space created by external expansion before fat grafting
permits more volume of graft to be inserted before high subcutaneous interstitial
pressures. It is this high interstitial pressure that often limits the graft volume that
can be achieved in more conventional grafting techniques. Our collective experience
with nearly 100 patients treated with external expansion and fat grafting revealed
that the single most important determinant of final volume augmentation was the
pregrafting volume expansion. We demonstrated a linear dose-response curve with
better expansion, leading to larger augmentations.
The concept of megavolume grafting after expansion is illustrated. The block of tis-
sue is first shown as maximally filled with fat grafts; it is then overfilled to crowding;
next, temporary three-dimensional stretching is done of that block of tissue, show-
ing how many more grafts can be placed in the expanded and hypervascular space.
Three-dimensional matrix
expansion (2  Dimension)
Maximal
grafting
Overgrafting
Maximal grafting
in expanded matrix
Baseline recipient space
(hypothetical block of tissue)
Expanded recipient space

2323
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
With Brava preexpansion, the patient and the expansion bra drive the volume of ex-
pansion, not the injected fat. In conventional fat grafting techniques, grafted fat is
required to act in four key ways:
1. To serve as an internal positive pressure expander
2. To survive by oxygen diffusion for 5 to 7 days
3. To eventually reconnect its capillary circulation to that of the recipient site
4. To remain viable and to act as a spacer
This first demand, the internal positive pressure expansion, theoretically works
against the other three demands and probably leads to adipocyte necrosis. Brava po-
tentially relieves the adipocyte from this first burden.
Many breasts demonstrate a range of deformities, from subtle, often underappreci-
ated, internal ligamentous constrictions to tuberous or severely constricted breasts.
Some of the more subtle effects, like occult double-bubble deformities, are only ap-
preciated at the time of prosthetic breast augmentation when internal tension and
volume changes exacerbate these underlying deformities. Using our external preex-
pansion system before fat grafting serves two valuable functions in reshaping breasts:
1. Deformities, even subtle ones, can be demonstrated to the patient before any
surgical intervention is performed.
2. During fat grafting, internal scar ligaments can be selectively lysed percuta-
neously using three-dimensional mesh grafting, or the Rigottomy technique,
described on p. 2334.
By increasing the recipient site space, there is less dependence on concentrating the
donor volume, which may reduce the need for time-consuming, high-speed cen-
trifugation and syringe-to-syringe fat transfer. Eliminating high-speed centrifugation
from our procedure has resulted in the following advantages:
1. Reduced transfer to smaller syringes, less air exposure, less potential con-
tamination.
2. Less-concentrated fat can be injected, because there is more space in the re-
cipient site.
3. Less-concentrated fat disperses better and leads to less clumping of the graft.
4. Less-concentrated fat flows better, resulting in less clogging and less poten-
tial cell trauma.
5. Fat grafting efficiency is improved, allowing the surgeon to graft large vol-
umes even in patients with a low BMI.
6. The operation can be performed in 2 hours or less.
Using the Brava system to preexpand the recipient site has emancipated the technique
of megavolume fat grafting from the need for high-speed centrifugation and its po-
tential disadvantages.

Choice of Fat Grafting Technique
Donor cells have the highest chance of survival with the technique that best ensures
an even, three-dimensional dispersion of the fat. There are currently two methods of
fat grafting: the “mapping” technique and the “reverse liposuction” technique (see
technique descriptions later in this chapter). There are presently no data on which
technique yields a better result. Each of us employs a different method, yet our in-
dependent volumetric data in breast augmentation is nearly identical, with an aver-
age volume increase of 250 cc at 6 months by MRI. Overall, the mapping technique
may be more suitable for surgeons beginning megavolume fat grafting for breast aug-
mentation, because it is more exacting and deliberate. For breast reconstruction, it
is clearly beneficial, especially in scarred areas caused by mastectomy and/or irradi-
ation, where a careful and deliberate graft placement is necessary. The reverse lipo-
suction technique is more time efficient and can be used in cases in which there is
no internal breast scarring, no dense adherence of skin to the chest wall, and where
the breast is adequately expanded.
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Part XI  Breast Surgery
Cautions When Grafting Fat to the Breast
In grafting to the breast, the physician should avoid the following:
1. Grafting the parenchyma itself, because it is traumatic to the gland, and there is an
increased risk of infection, because the ducts are not sterile.
2. Overgrafting; that is, grafting beyond what the recipient site can bear. A telltale sign
of overgrafting is increased tissue turgidity and/or peau d’orange skin changes.
Overgrafting often leads to total graft loss.
3. Delivering macropackets of fatty tissue (from which central necrosis will lead to oil
cysts) instead of micropackets (which completely revascularize and survive).
4. Uneven grafting and grafting the same area twice to create uneven deposits or lakes.
Once the fat is grafted, the internal breast parenchyma pressure increases and con-
genital irregularities due to internal ligamentous tethering become more obvious.
This is commonly seen at the interface between the natural inframammary fold and
the newly augmented breast mound injection area. One of the advantages of fat graft-
ing the breast is its unique ability to correct the constricted, tuberous breast defor-
mity without any incision.

Preoperative Preparation of the Recipient Site
In no other procedure in plastic surgery is the preoperative preparation more vital
than in fat grafting to the breast with Brava preexpansion. Mammograms are per-
formed on all patients to obtain a baseline screening for breast pathology. Patients
have three-dimensional MRI or three-dimensional photographic imaging to deter-
mine preexpansion baseline volume. Before expansion begins, candidates for the pro-
cedure are given a specific “goal volume” to achieve and agree they will follow the
expansion guidelines. On a volumetric basis, a quantitative doubling of breast vol-
ume is the minimum goal set.
The expansion bra is then fitted on the patient by the nurse or by the surgeon, who
makes certain that the patient can apply the bra and achieve the suction on her own.
The bra comes in several dome projections and in several base diameter sizes and
the correct size must be selected for each patient. It is important to educate the patient
how to apply the bra so there is no room for error or lack of compliance during the
expansion process.
Surgeon’s Endpoints for Expansion
Surgery is not guaranteed unless the patient adequately expands. Patients are seen
weekly in the office to monitor compliance and to quantify the expansion progress,
and to make necessary corrections to the program. A standard doubling of breast
volume by three-dimensional imaging is realistic and is usually obtained in 3 weeks
in patients who follow the program of expansion. Although this process is planned
to take 3 weeks, it is not as much a matter of time as it is a matter of adequate vol-
umetric expansion. Some patients simply expand faster and better than others. In
our practice, we have seen patients expand to four to five times the initial volumes
in 3 weeks, whereas in other cases, we have seen patients who had little or no ex-
pansion after the same period of use. The duration of use in terms of hours per day
and the negative pressure during use are the two variables that can be modified to
achieve the desired expansion.
2325
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting

2326
Part XI  Breast Surgery
Patient’s Endpoints for Expansion
It is important to educate the patient about the extent of the desired expansion. Of-
ten patients think they need to expand to their desired breast size and then stop, but
this is not optimal. The Brava expansion should be greater than the desired volume,
so there is a much larger potential space created compared to the desired volume of
fat to be grafted. We have developed the “1-2-3 Rule” for our patients so they can
easily understand the endpoints of expansion while they visually monitor their
progress at home: If you are a “1” and you want to be a “2,” you must expand to a
“3.” A patient who wants to double her final volume must triple in expansion.
Technique
Markings
Patients arrive in the operating room on the day of surgery wearing their expansion
bra. Preoperatively, the patient is initially marked for areas to be suctioned, and the
breasts are marked circumferentially for areas of proposed needle insertions. Any
constricted areas are outlined for planned release using the percutaneous three-
dimensional mesh release, as described by Rigotti et al. Markings are placed at 8 to
10 proposed sites circumferentially around the breast. Once markings are completed,
the Brava bra is reapplied. Once in the operating room under general anesthesia, the
patient is positioned supine with the domes still in place and under manual bulb suc-
tion. The anesthesiologist monitors the suction intermittently during the liposuction
phase of the procedure, so the negative pressure can still be applied to maximize the
recipient site space.
1-2-3 Rule

Harvesting
Liposuction is performed using a 12-gauge 9- to 12-hole cannula. Smaller cannula
sizes produce less subcutaneous tissue trauma, promote faster recovery, and create
smaller fat parcels that result in better fat flow and less clumping. Multiple holes fa-
cilitate fat removal increasing both efficiency and speed. Two collection techniques
are currently employed.
Syringe Collection Method (Khouri)
2327
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
For the syringe method of fat harvesting, a spring-loaded, 300 mm Hg constant-
vacuum (KVAC) syringe is connected with a nonclogging atraumatic tissue valve and
intravenous tubing to a 100 cc sterile intravenous bag on the field. Cocking the spring
activates the syringe suction, and once the syringe is full, pushing the plunger down
again purges the lipoaspirate to the collection bag and cocks the spring again. The
cycle is repeated until the bag is full, at which time the assistant replaces it with an-
other empty bag. Fat is harvested in a completely closed system. There is no expo-
sure to air and minimal chances of bacterial contamination. Excessive air exposure is
known to be detrimental to adipocyte survival. This technique initially collects the
fat into 100 cc intravenous bags, which is efficient for the next step in the process.
Machine Method (Del Vecchio)
Using a sterile “in-line” container, fat is aspirated at lower than 1 atm (500 mm Hg)
suction by attaching a sterile, clear, collection canister to a standard vacuum ma-
chine off the sterile field. A 3 mm 9-hole cannula with a wide handle and ribbed con-
nector end is used to attach to the liposuction tubing. Maximal negative machine
pressures are avoided when using this technique, and vaporization of the fat in the
Lipoharvesting with the KVAC syringe
and a 12-gauge, 12-hole cannula

2328
Part XI  Breast Surgery
A 3 mm multihole cannula fused to an ergonomic handle reduces operator fatigue
and reduces instrument breakdown at the handle-tubing interface.
The in-line system is shown, with left-hand tubing going to the cannula and right-
hand tubing headed off the field to a liposuction machine. The sterile canister on the
field collects the fat.
Fat Preparation
Once the fat is collected, one of two general methods for removing unwanted crys-
talloid solution is employed: the bag centrifugation method advocated by Khouri
and the large syringe method advocated by Del Vecchio.
collection canister is to be avoided at all costs. This technique initially collects the
fat into 1200 cc canisters and can be performed with existing equipment used in an
operating room.

Bag Centrifugation Method
2329
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
With the bag centrifugation technique, 100 cc intravenous bags are hung on a hand-
spun 5:1 gear-ratio spinner and centrifuged at low rpm (approximately 30 G) for
several minutes. It takes minutes to prepare the 600 to 800 cc we often need for a bi-
lateral augmentation, compared with hours for high-speed centrifugation. The in-
fra natant crystalloid solution is tapped off, and the fat is ready for reinjection.
Large Syringe Method
By changing several in-line collection canisters during the machine liposuction, the
canisters are allowed to stand for 10 minutes, allowing fat to separate from crystal-
loid. This fat is then drawn up into 60 cc syringes directly from the collection can-
ister, and placed in a megavolume centrifuge. Additional low G force centrifugation
of these 60 cc syringes is optional.
In the large syringe method, the passive use of 1 G separates the fat from the un-
wanted crystalloid solution by the use of stiff collimated containers—the canister
and then the 60 cc syringes. This occurs passively and takes minimal additional time.

The greater the overexpansion of the recipient site space, the less important is pro-
duction of ultraconcentrated fat. Overexpansion of the recipient site affords the op-
portunity to inject less-concentrated fat, which theoretically less traumatized, flows
better, disperses better because it is less concentrated, and takes less operative time
and manpower to process. The emphasis on overcorrection of fat grafting, with re-
sultant overcrowding, interstitial hypertension, and fat necrosis, can now be applied
to overexpansion of the recipient site before fat grafting.
Washing the cells with saline solution is avoided, because it is thought that this may
remove essential components such as stem cells and growth factors from the fat slurry.
Placement
Once the fat is separated from unwanted crystalloid solution, injection into the breast
begins. Injections are performed using a 15 cm Coleman side-hole needle.
The Mapping Technique (Khouri)
If a closed-system bag collection and centrifugation technique is used, the fat is sim-
ply drawn back out of the intravenous bags using small (3 to 5 cc) handheld syringes
that are connected directly to a 14-gauge blunt, curved, side-hole cannula.
2330
Part XI  Breast Surgery
A number of 60 cc syringes are shown loaded
onto the sterilized low G force bucket-handle
centrifuge. Spinning decanted fat for 3 minutes
at 40 to 50 G results in removal of 15% to 20%
additional crystalloid solution, as demonstrated.
Markings for the mapping technique for fat in-
jection in the expanded breasts are shown.

The markings are made in the recipient areas to aid in the systematic, diffuse, and
even injection of the entire recipient site. Ten to 12 circummammary and 4 circum-
areolar needle puncture entry sites are usually made with a 14-gauge hypodermic
needle. Radially fanning tunnels from each site provide well-distributed, diffuse sites
for insertion of the grafts.
Through each entry point the 15 to 25 cm long cannula makes multiple tunnels that
fan out radially, and 2 to 4 cc of fat suspension is injected on withdrawal. The can-
nula is then inserted into another adjacent entry point and the process is repeated
to yield a three-dimensional weave pattern that crisscrosses the recipient space to
provide even coverage. The grafts are deposited at multiple levels, deep from the sub-
pectoral plane, to the pectoralis muscle, to the base of the breast just above the pec-
toralis fascia, to the subcutaneous space immediately subjacent to the dermis.
2331
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
Care is taken to disperse the graft as much as possible and to inject on withdrawal
of the needle along an axial track. In a well-expanded breast, the superficial tissues
from the skin to the breast parenchyma open up into three potential planes. Fat is
first grafted in the most superficial subdermal plane, then in the middle subcutaneous
plane, then in the deeper periglandular space. These are staggered along the multi-
ple entrance needle holes. Grafts through the even-numbered holes are distributed
most superficially, odd-numbered ones deeper, and periareolar deepest. We prefer to
first fill up the preglandular recipient site, because it is more effective than filling the
deeper subglandular layer when the same volume of fat is placed and survives. (Golf
balls provide more contour projection when placed under the sheet compared with
under the mattress).
In a well-expanded breast we can often graft over 200 cc in this superficial plane.
Care must be taken, however, to avoid the “peau d’orange” effect of excessive graft-
ing since this will cause total graft loss. Then, if there is more graft available, we graft

the deeper planes beginning under the muscle, progressing to inside the muscle, to
above the fascia, to subglandular. Direct injection into dense breast tissue is not per-
formed. This technique is more accurate and deliberate, requiring more time. It is
recommended for those who are initially performing fat grafting to the breast. In ad-
dition, it requires that the operator deploy the plunger and withdraw the needle at
the same time.
Reverse Liposuction Technique (Del Vecchio)
If fat has been harvested and collected using the machine and large syringe technique,
the fat is already in 60 cc syringes. These syringes are simply loaded onto the Cole-
man cannula and injected into the breast. The reverse liposuction technique uses
6 to 8 insertions on the breast along the inframammary fold and spaced 4 to 5 cm
laterally toward the axilla. The inframammary fold insertions are usually made 1 cm
below the native inframammary fold, because this will descend 1 to 2 cm, similar to
the effect seen in augmentation with breast prostheses.
Insertion holes are positioned in a pattern around the breast periphery. Insertions
along the medial upper quadrant are generally avoided to reduce the possibility of
pigmented large needle scars, as this is the part of the breast often seen in low cut
clothing. Using a “reverse liposuction” technique, gentle pressure is placed on the
plunger of the 60 cc syringe and the cannula is inserted and removed in a relatively
rapid fashion along multiple axial directions.
A straight, 15 cm, blunt, side-hole, 16-gauge Coleman cannula loaded directly onto
60 cc syringes is used to inject the fat using a controlled “to and fro” liposuction
movement with constant light depression on the plunger. With every pass of the can-
nula the direction is changed slightly to create a fanning vector pattern. This is re-
peated in each different insertion site and at multiple planar levels from the base of
the breast. The axillary insertion is also used to place graft tissue in the submuscu-
lar position; this approach is thought to be the safest method of navigating the sub-
pectoral space. An example of optimizing a technique versus maximizing a variable,
the reverse liposuction technique strives to optimize graft insertion times with the
potential for less exact dispersion of fat if not effectively performed. Another poten-
tial benefit of the reverse liposuction technique is that 60 cc syringes generate lower
maximum pressures than do 5 cc syringes, which generate higher pressure. There-
fore, if there is a blockage of flow along the insertion cannula because of clumping,
this will occur at a lower pressure using a 60 cc syringe, with less potential damage
to the grafted cells and less likelihood of pushing the blockage through, creating a
bolus.
2332
Part XI  Breast Surgery

The maximum pressure generated in a 60 cc syringe is lower than that of a 3 or
5 cc syringe. There is thought to be less pressure and trauma on the adipocytes us-
ing the larger syringe. If the graft is placed at a rate of 1 cc of volume in 2 to 3 sec-
onds, this results in 2 to 3 minutes per 60 cc syringe of fat, or 10 to 15 minutes to
augment 300 cc of volume into each breast.
A summary of the two techniques is outlined in the table.
2333
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
Comparison of Techniques for Harvest, Preparation, and Grafting of Fat
Syringe Method
Mechanical Methods
Aspiration cannula
12-gauge Luer-Lok
3 mm ergonomic handle
Aspiration force
Handheld syringe
Machine assisted
Operator ease of use
Springloaded
Vacuum unit
Air exposure
Minimal to none
Mild to moderate
Negative pressure
Constant
Constant
Collection chamber
100 cc IV bag
1200 cc rigid canister
Crystalloid separation
Low G force centrifuge
Low G force centrifuge
Injection cannula
16-gauge blunt curved
16-gauge blunt straight
Injection force
3 cc syringe (high)
60 cc syringe (low)
Injection technique
Mapping
Reverse liposuction
Aesthetics of Breast Size and Shape
Immediately After Grafting
There is a major paradigm shift between what a surgeon should expect from an aes-
thetic perspective after prosthetic breast augmentation and augmentation using
megavolume fat grafting. Using breast implants, the “on-table” aesthetics can be crit-
ically examined for size, symmetry, and position and are more “WYSIWYG” (what
you see is what you get). In contrast, the immediate on-table result with megavol-
ume fat grafting represents the first stage of a dynamic process. First, there is a volume
of interstitial fluid from the expansion itself and crystalloid solution in the donor
fat; this will reabsorb in the first 3 to 5 days after grafting. The surgeon should not
be too concerned with the appearance of breasts that look too large on the table but
should focus on the volume of material that was grafted. Second, because the aug-
mentation is intraparenchymal rather than the single-cavity volume enhancement
achieved with implants, there are more on-table surface irregularities that will re-
solve in the early postoperative period; these require no additional manipulation.

2334
Part XI  Breast Surgery
When external negative pressure is placed on the breast, Brava preexpansion may
accentuate breast contour irregularities that are caused by inframammary fold con-
strictions, tuberous breast constrictions, or internal scars in the breast. It is impor-
tant to recognize these irregularities while the patient is still on the operating table.
Breast shape can be addressed in augmentation patients, especially double-bubble
contour deformities that occur along the inframammary fold.
Shape Modification Using Three-Dimensional Meshing:
The Rigottomy Technique
We use a technique first described by Gino Rigotti to release scars in breast recon-
struction with fat grafting. He performs a three-dimensional mesh release of the scar.
This is a very powerful way to release a contracture without making subcisions; it
also avoids creating linear tissue planes that end up as loculated cavities with fat
necrosis. Instead, the technique releases the contour deformities of the breast paren -
chyma and expands it in three dimensions like a skin graft is meshed to expand in
two dimensions. This creates multiple microcavities where small deposits of fat can
survive. We have named this technique the Rigottomy. The grafted fat fills the small
cavities in the three-dimensional released structure and restores the attractive, round
breast shape. By percutaneously releasing fibrous constrictions, the inframammary
fold can be lowered, the constricted tuberous breast can expand in three dimensions,
and the overall shape of the breast can be modified dramatically.
Immediately after fat grafting, the injected fat provides an internal traction effect to
help identify specific areas of deforming scar or ligamentous bands, as seen in this
patient (left). After insertion of an 18-gauge needle and release of the scar bands (cen-
ter), the irregularity is released and the fat immediately fills the space created, chang-
ing the shape to a more aesthetic result (right).

In a dense breast that exhibits a double-bubble contour deformity at the inframam-
mary fold (right of nipple) and upper pole (left of nipple), multiple needle band re-
leases, or Rigottomies, may be required, as seen in this patient.
Postoperative Management
Postgraft care is a very important factor in graft survival. One would not expect a
skin graft to survive if it were subjected to motion and shearing in the early postop-
erative period. Therefore, in the first 24 hours after grafting, no external compres-
sion or negative pressure should be applied. Beginning 24 hours after grafting, pa-
tients are placed in Brava domes that are set at a low constant pressure; the patient
wears the Brava bra for the first 5 to 7 days after the grafting procedure.
The use of Brava in the postoperative period may act as a splint. As a fundamental
principle of plastic surgery, it is crucial to maintain surgically released and grafted
constrictions or scars open with a splint until the graft matures. The low negative
pressure exerted by the expansion bra may help immobilize the fat cells and aid in
neovascularization to the graft. It is also postulated that the lipoaspirate-filled slurry
in the interstitial space held open with the Brava bra functions like a multitude of
growth chambers to stimulate fat formation. In any event, application of the bra in
the postoperative period certainly protects the breast from external trauma, which
could serve to shift the grafts and potentially disturb neovascularization.
Our experience has shown that if the patient continues to wear the Brava bra after
the first postoperative week for 10 hours per day for several months, she will tend
to keep the early augmentation result as permanent tissue, with very little volume
loss over the next year. In essence, this is the original expansion effect boosted by fat
grafting. Therefore we currently recommend that the patient maintain the external
tension on the tissue for 10 hours per day over the next 8 to 10 weeks; this in our
experience greatly enhances the megavolume graft results. This creates a multitude
of active growth chambers in which Morrison et al have shown stimulation of fat
growth.
2335
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting

Results
One-Stage Breast Augmentation
2336
Part XI  Breast Surgery
This 24-year-old nulliparous woman desired increased breast size. She was concerned
with size and requested a rounder shape. Her breasts were relatively symmetrical,
with moderate inferior constriction in the lower poles. She did not want breast im-
plants. She initially underwent expansion with a Brava handheld pump used 8 hours
per day for 3 weeks. She was a very compliant patient, and her expansion proceeded
well over serial office visits. After 3 weeks of expansion she underwent injection of
280 cc of fat into each breast, harvested by liposuction of the thighs. Six months af-
ter grafting, her result is stable. Even in patients in whom liposuction alone would
not likely be considered, it is possible to obtain a sufficient amount of fat.

One-Stage Breast Augmentation for Deflated Breasts
After Implant Removal
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Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
This 59-year-old woman had previously had silicone breast implants that were re-
moved 15 years earlier because of implant complications. At the time of her implant
removal, her breast tissue had atrophied and thinned, and her surgeon had performed
a Wise pattern breast lift to remove excess skin. The patient was not happy with the
size reduction and with the deflated appearance, but she did not wish to undergo
reinsertion of breast implants.
When she presented for a thighplasty involving initial thigh liposuction, to be fol-
lowed 6 to 8 months later by a medial thigh lift, the possibility of using the liposuc-
tion fat for her breasts was discussed with her. The patient wore the Brava bra, us-
ing the higher-pressure hand pump, for 3 weeks preoperatively during the late
afternoon/early evening for approximately 8 hours per day. This patient, a practic-
ing physician, had a busy schedule, and compliance was a challenge. Despite her less
than ideal compliance, she had enough parenchymal and skin laxity to expand well
and to receive 600 cc of fat in each breast during her thigh liposuction. After 6 months
she demonstrated a significant, sustained volume increase. Patients who have breast
implants removed have already had significant skin expansion as well as subcuta-
neous paren chymal redundancy once the implants are removed. This is an opportu-
nity to “backfill” this space with fat.

Two-Stage Breast Augmentation for Constricted
Tuberous Breasts
Constricted tuberous breasts can be augmented and reshaped with external expansion
and megavolume fat grafting; usually two stages are required to achieve sufficient
volume.
2338
Part XI  Breast Surgery
This 32-year-old patient with tuberous breast deformity desired increased breast size
and improved shape. She had constricted inframammary folds and herniation of the
nipple-areolar parenchyma. She did not want breast implants. She initially under-
went expansion with a Brava Sport Pump, a low-pressure battery-operated pump,
for 3 weeks before her first fat grafting procedure in which 300 cc of fat was injected
into each breast, and she underwent three-dimensional mesh release and periareo-
lar reduction. It was thought that the low negative pressure created by the Sport
Pump was not optimal and that additional expansion could have been achieved with
a handheld pump generating more negative pressure.

After 4 months she underwent a second round of preexpansion using a handheld
pump and had a second round of grafting, with 350 cc of additional fat per breast.
Her results after her first procedure and 8 months after her second injection series
demonstrate a significant increase in volume and improved breast aesthetics.
Concluding Thoughts
Fat grafting to the breasts fell into disrepute 20 years ago because of a lack of effi-
cacy in technique and the much-discussed potential for obscuring the detection of
cancer. Over time, however, these concerns have been largely addressed as applica-
tions for fat grafting have expanded.
Today fat grafting to the breast is still controversial, but efficacy is no longer a ques-
tion. To establish efficacy, each of us has conducted an independent prospective study
with a total of 100 patients followed for 6 years. We have carefully monitored our
patients with preoperative and postoperative MRIs and confirmed long-term fat graft
survival after breast augmentation of 220 to 250 cc per grafting session. None of
our patients had a suspicious lesion, and breast radiologists have identified no sig-
nificant findings on the imaging.
There is no support in the literature for the theory that fat grafting might stimulate
the growth of breast cancer. Plastic surgeons have routinely transferred large amounts
of fat for breast reconstruction. That experience spans a few decades and hundreds
of thousands of patients, with no suggestion whatsoever of increased cancer recur-
rence in a cancer-prone recipient site. Delay and Rigotti have reviewed their decade-
long experience with more 1000 patients grafted after mastectomy and lumpectomy
and found no evidence to suggest that the procedure promotes cancer growth or re-
currence even in the cancer prone residual breast.
2339
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
Preexpansion MRI of patient
MRI 6 months after second fat grafting

The potential but unproven benefits of stem cell–enriched fat and cell protectants
are exciting new avenues for investigation; these must be evaluated through clinical
studies, comparing these results to those using unadulterated adipocyte grafts as a
benchmark. Over the next decade, these issues and the relative safety of the proce-
dure will be better defined. Standardization, clinical improvements in technique, and
protocols for preoperative and surveillance breast imaging are needed to define pa-
tient safety and the role of fat grafting as a viable alternative for breast augmentation.
Clinical Caveats
 Successful fat grafting requires optimization of four components: (1) the grafted
tissue with its viability and growth potential, (2) the size and quality of the recip-
ient site, (3) the grafting technique, and (4) care after grafting. The outcome will
be as good as the weakest link. There is no point in investing excessively in one
factor if another step is neglected.
 Preparation of the recipient breast with the Brava external expansion system re-
quires a minimum of 2 weeks of expansion.
 The more intensive the use of Brava, the faster the expansion; patient compliance
is essential.
 Expansion makes the recipient tissue compliant and allows the diffuse placement
of large graft volumes with optimal preservation of the graft to the recipient in-
terface.
 For patients with constricted tuberous breasts, the Rigottomy technique is bene-
ficial. It provides for the percutaneous release of fibrous constrictions in the in-
framammary fold so the constricted breast can be expanded in three dimensions,
thereby facilitating the modification of the overall shape of the breasts.
2340
Part XI  Breast Surgery
Suggested Readings
Aboudib Júnior JH, Cardoso de Castro C, Gradel J. Hand rejuvenescence by fat filling. Ann
Plast Surg 28:559-564, 1992.
ASPS Guiding Principles. Fat transfer/fat graft and fat injection. Posted Jan 2009. Available
at
guiding_principles/ASPS-Fat-Transfer-Graft-Guiding-Principles.pdf.
Coleman SR, Mazzola RF, eds. Fat Injection: From Filling to Regeneration. St Louis: Qual-
ity Medical Publishing, 2009.

2341
Chapter 64  Breast Augmentation With External Expansion and Fat Grafting
Cytori Therapeutics. Adipose-derived stem & regenerative cells improve fat graft retention
in preclinical study. Press release, December 15, 2007. Available at

Delay E, Garson S, Tousson G, Sinna R. Fat injection to the breast: technique, results, and
indications based on 880 procedures over 10 years. Aesthet Surg J 29:360-376, 2009.
Herman AR. The history of skin grafts. J Drugs Dermatol 1:298-301, 2002.
Illouz YG. Body contouring by lipolysis: a five year experience with over 3000 cases. Plast
Reconstr Surg 72:591-597, 1983.
Kaufman MR, Miller TA, Huang C, et al. Autologous fat transfer for facial recontouring: is
there science behind the art? Plast Reconstr Surg 119:2287-2296, 2007.
Khouri RK, Del Vecchio DA. Breast reconstruction and augmentation with Brava external
expansion and fat grafting. In Coleman SR, Mazzola RF, eds. Fat Injection: From Filling
to Regeneration. St Louis: Quality Medical Publishing, 2009.
Khouri RK, Spear S. A prospective study of autologous fat grafting for breast augmentation.
Georgetown University, Jan 2010. Available at

Kurita M, Matsumoto D, Shigeura T, et al. Influences of centrifugation on cells and tissues in
liposuction aspirates: optimized centrifugation for lipotransfer and cell isolation. Plast
Reconstr Surg 121:1033-1041, 2008.
Lewis CM. Comparison of the syringe and pump aspiration methods of lipoplasty. Aesthetic
Plast Surg 15:203-208, 1991.
Melike E, Erdem T, Ayhan N, et al. The effects of the size of liposuction cannula on adipocyte
survival and the optimum temperature for fat graft storage: an experimental study. J Plast
Reconstr Aesthet Surg 62:1210-1214, 2009.
Nguyen J, Medina M III, McCormack M, et al. Enhanced fat protection and survival in fat
transplantation via treatment with poloxamer 188. J Surg Res 151:210-211, 2009.
Peer LA. Cell survival theory versus replacement theory. Plast Reconstr Surg 16:161-168,
1955.
Rigotti G, Marchi A, Baroni G. Structural fat grafting for the regeneration of irradiated tis-
sue. In Coleman SR, Mazzola RF. Fat Injection: From Filling to Regeneration. St Louis:
Quality Medical Publishing, 2009.
Rigotti G, Marchi A, Stringhini P, et al. Determining the oncological risk of autologous
lipoaspirate grafting for post-mastectomy breast reconstruction. Aesthetic Plast Surg
34:475-480, 2010.
Shiffman MA, Mirrafati S. Fat transfer techniques: the effect of harvest and transfer meth-
ods on adipocyte viability and review of the literature. Dermatol Surg 27:819-826, 2001.
Ullmann Y, Shoshani O, Fodor A. Searching for the favorable donor site for fat injection: in
vivo study using the nude mice model. Dermatol Surg 31:1304-1307, 2005.

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Fat Grafting to Treat
Capsular Contracture

GINO RIGOTTI, ALESSANDRA MARCHI,
GUIDO BARONI, PAOLO PATETE, ANDREA SBARBATI
CHAPTER 65

C
apsular contracture is a postoperative complication following aesthetic and re-
constructive surgery of the breast. Clinical studies report an incidence of 7%
to 20%, without any specific correlation with the surgical procedure (augmentation
or reconstruction).
From a clinical standpoint, capsular contracture results from a progressive fibrotic
physiologic process that follows the insertion of a foreign body; the body attempts
to wall off the object. After breast augmentation surgery in which implants are placed,
normal capsule formation leads to a thin, soft layer of fibrotic tissue around the im-
plant, with no evident morphologic modification of the breast. Capsular contracture
is characterized by progressive hardening and thickening of the periprosthetic tissue
layer, leading to retraction. The result is deformation of the implant, resulting in ev-
ident breast morphologic changes toward a hemispheric shape; the breast is drawn
upward, causing pain and, in the worst cases, extrusion of the implant. Although
the causes of capsular contracture have not been entirely elucidated, postoperative
radiation therapy has been reported to significantly increase its incidence.
According to Baker’s classification, capsular contracture is grouped into four cate-
gories:
 Baker I capsular contracture is characterized by a soft breast without signifi-
cant scar tissue.
 Baker II capsular contracture involves palpable scar tissue around the implant;
however, the capsule is not visible.
 Baker III capsular contracture is associated with visible and palpable harden-
ing, leading to a deformed breast shape.
 Baker IV capsular contracture, the most severe level, involves hardening and
a palpable, visible capsular deformation and often a cold, hard breast that is
very painful even to mild palpation.
Capsular contracture is conventionally treated with surgery (typically implant re-
placement) or capsulectomy in an attempt to restore normal breast morphology and
reduce the clinical symptoms. However, in a high percentage of cases, the beneficial
effects of surgical revision are not long lasting, and the contracture redevelops, re-
quiring further surgical intervention.
The use of autologous fat grafting for the treatment of capsular contracture was first
attempted after observation of the substantially fibrotic and avascular nature of the
periprosthetic tissue.
2344
Part XI  Breast Surgery

This microscopic image of a periprosthetic capsule indicates the presence of con-
tracture. This is typical of ischemic tissue, with no or few blood vessels present. Re-
cent clinical studies demonstrate that transfer of lipoaspirate (autologous fat graft-
ing) is an effective treatment for many of the pathologic conditions related to
ischemia. Thus fat grafting is proving a reliable therapeutic strategy for the treatment
of capsular contracture.
Although the mechanisms associated with the regenerative properties of lipoaspi-
rate are not yet completely understood, they have been explained by the action of
mesenchymal multipotent cells, adipose-derived stem cells (ADSCs or ASCs), which
have been found in significant quantity in harvested lipoaspirate. The capability of
these cells to produce angiogenic and growth factors appears to be enhanced when
they are grafted in a biologic environment with altered microcirculation or when fat
grafting is followed by mechanical stretching for volumetric enhancement.
The advantages of fat grafting in clinical practice include the ease and accessibility
of harvesting lipoaspirate from different donor areas, the simplicity of the purifica-
tion procedure, and the permanent nature of the results of fat transfer. The use of
micrografts has led to improved “take” of the transferred lipoaspirate.
2345
Chapter 65  Fat Grafting to Treat Capsular Contracture
The advantages of fat grafting in the treatment of severe postradiation effects are
demonstrated in this patient. On the left, she is seen following radiation therapy. On
the right, after autologous fat grafting, a newly generated thick layer of fatty tissue
is evident during reconstructive surgery.

2346
Part XI  Breast Surgery
Indications and Contraindications
Women who have had implant-based reconstruction or cosmetic breast augmenta-
tion and developed severe capsular contracture (Baker grades III or IV) are ideal pa-
tients for fat grafting. Many of these patients have undergone a conventional ap-
proach to the treatment of capsular contracture, and the condition has recurred.
Patient suitability for fat grafting depends on whether the individual has a sufficient
amount of fatty tissue to be harvested (70 to 200 cc for each grafting session; on av-
erage, three or four sessions are required). There are no specific contraindications to
fat grafting, such as patient age or health issues, as long as the patient is able to tol-
erate the deep sedation required for tissue harvesting and grafting.
Preoperative Assessment and Planning
The severity of capsular contracture and its location must be carefully assessed so
the surgeon can estimate the correct amount of fatty tissue required and make a pre-
liminary comparison of the volume available at the donor site in relation to the re-
quirements of the recipient site, without putting too much pressure on the infiltrated
lipoaspirate. Generally, no additional fat is grafted to account for absorption; the
effects of absorption are reduced by repeated lipoaspirate sessions. Grafting features
fat deposition in a large area around the contracture site, plus localized deposition
to treat the most evident signs of retraction and fibrosis.
Fat grafting is planned by establishing the number and location of the entry points
and the direction of the injection tunnels; these parameters can be refined during sur-
gery. The goal is to achieve optimal uniformity of distribution around and within
the contracture area and to avoid significant overlaps and gaps. Lipoaspirate must
be distributed all around the capsule with no perforation of the capsule or the pros-
thesis. The purified fat is grafted between the skin and the capsule.

Surgical planning can be enhanced with computer-assisted planning tools. These pro-
vide volumetric anatomic models of the target area based on MR scans (with the pa-
tient prone), or they register an MR atlas on the patient’s surface data acquired by
laser surface scanning. An example of the targeted volume and graphic feedback of
optimized tissue deposition pathways is shown above. The computer tool allows the
surgeon to visualize and segment the target structures, to establish the initial graft
geometry by defining preliminary entry point positions and insertion angles, and to
define forbidden areas and/or volumes that must be avoided, such as the implant.
The tool features automatic procedures that optimize the grafting sequences by means
of volumetric algorithms that optimize the uniformity of tissue distribution.
The operative plan created with these computer tools can be viewed during the pro-
cedure to guide the surgeon through the sequence of deposition paths. A further step
toward the highest possible accuracy of fat grafting is represented by the use of in-
traoperative surgical navigation devices based on real-time, three-dimensional lo-
calization technologies (infrared optical tracking systems and electromagnetic lo-
calizers) that are registered with the individual patient’s surgical plan.
The surgeon must thoroughly discuss the procedure with the patient, particularly
the fact that the technique requires multiple surgical sessions at monthly intervals
and that the entire treatment cycle can be as long as 12 months.
2347
Chapter 65  Fat Grafting to Treat Capsular Contracture

2348
Part XI  Breast Surgery
Operative Technique
The operative technique is organized in three phases.
Phase I: Harvesting the Lipoaspirate
The patient is given a local anesthetic and deep sedation for harvest of fatty tissue.
Twenty minutes before surgery begins, antibiotics are administered. Typically, lipoaspi-
rate is harvested from the medial area of the knee, the abdomen, or the trochanteric
regions and the flanks. The identified donor area is infiltrated with a cold saline so-
lution of 1:400.000 epinephrine and 20 ml lidocaine 0.5% for every 500 ml. Har-
vesting is performed by means of a 2 mm diameter blunt-tip cannula with a dull dis-
tal opening that is connected to a 50 cc Luer-Lok syringe. Aspiration must be
performed without applying excessive negative pressure. It is important to begin har-
vesting with superficial liposuction, extending this to the deeper layers.
Phase II: Purifying the Lipoaspirate
The harvested fatty tissue is purified to remove a large part of the triglycerides stored
in the tissue to facilitate their rapid clearance after injection. At the end of harvest-
ing, the cannula is removed from the syringe and replaced with a plug. The plunger
is removed and the syringe is placed directly into a centrifuge (IEC Medispin-6). The
syringes are centrifuged at 1000 rpm for 1 minute; this produces three layers within
the syringe: the upper level contains oil from ruptured adipocytes; the middle level
contains the purified lipoaspirate; and the lowest level contains blood, saline solu-
tion, debris, and residual drugs. The upper and lower levels are discarded by using
neuropads for absorption and opening the plug, respectively. The purified lipoaspi-
rate is transferred to a 2 cc syringe and is ready for injection.
Phase III: Injecting the Lipoaspirate
The same local anesthetic that is employed for harvesting is injected at the recipient
site with the patient under deep sedation; blunt needles are used to avoid vessel dam-
age. Coleman type III and V cannulas are used for lipoaspirate deposition (especially
effective in irradiated tissue).
There are two main issues to be considered in lipoaspirate deposition:
1. The quantity of lipoaspirate to be administered
2. The homogeneity of the deposition
The quantity of lipoaspirate to be injected is crucial. Several issues need to be con-
sidered: stiffness of the subcutaneous tissue and skin retraction (peau d’orange) are
highly critical. The quantity of lipoaspirate is decided on a patient-specific basis. It

is important to avoid too much pressure on the infiltrated lipoaspirate; at the end of
the procedure, some elasticity within the treated area must be preserved. It is crucial
that fatty tissue be placed with the highest homogeneity within and around the tar-
geted area. Anecdotally, this homogeneity is believed to increase the regenerative ef-
fects of the treatment. Graft homogeneity is the rationale for using computer-assisted
planning and surgical navigation for lipoaspirate grafting.
As a general rule, the placement of very small aliquots of lipoaspirate for each in-
sertion path is the key to obtaining remarkable, lasting results. Injection of bulky
quantities will usually result in the development of oil cysts and/or macrocalcifica-
tions. NOTE: The thread of lipoaspirate must be placed while withdrawing the can-
nula to minimize the risk of arterial or venous embolization.
The number of treatments depends on the patient’s initial clinical picture and on the
patient’s response to the therapy. In our experience, three to six treatments are suf-
ficient to obtain the desired results. Capsular contracture following radiation ther-
apy is much more severe and requires more fat grafting procedures. There is no evi-
dence of any contraindication to additional fat grafting sessions.
Postoperative Care
DONOR AREAS
Immediately after the procedure, ice packs should be placed for
4 to 6 hours over any areas from which fat was harvested. The patient wears an elas-
tic pressure garment for about 2 weeks.
TREATED AREA
As in the donor area, ice packs are positioned over the treated area
immediately after the procedure and kept in place for 4 to 6 hours.
Immediate and Late Complications
Donor Areas
In the postoperative period, ecchymosis and small hematomas are often present but
normally disappear within 2 to 3 weeks. Local administration of epinephrine is ex-
tremely important to avoid this problem. Irregularities can be avoided by using the
techniques recommended for liposuction.
Infection
Infection is a very uncommon complication—the incidence is normally much less
than 0.5%. This probably is associated with antiinflammatory properties of the lipo -
2349
Chapter 65  Fat Grafting to Treat Capsular Contracture

2350
Part XI  Breast Surgery
aspirate as a result of T lymphocyte inhibition. Nevertheless, we strongly advise giv-
ing a single prophylactic dose of an intravenous antibiotic before the procedure.
Venous and Arterial Injuries
The most common problem associated with fat grafting is damage to veins or small
arteries, resulting in ecchymosis, and occasionally hematomas. To avoid these prob-
lems, sharp needles should not be used, even for injection of a local anesthetic. Periph-
eral arterial occlusion has never occurred in any of our patients after the procedure.
Results
In this patient, total reconstruction of the right breast with an implant was compli-
cated by moderate capsular contracture. There were wrinkles that were more evident
in the upper quadrants and flattening of the lower pole, as well as upper prosthesis
dislocation and a volumetric deficit. Four fat grafting sessions were sufficient to re-
solve the scar retraction and contour waviness and to produce new adipose tissue in
the targeted areas; this led to restoration of breast morphology comparable with that
of contralateral breast.

2351
Chapter 65  Fat Grafting to Treat Capsular Contracture
This patient underwent implant-based breast reconstruction, which resulted in a sig-
nificant Baker III capsular contracture. Retraction had led to upward dislocation of
the implant, with excessive bulging in the superior quadrants and deformation of
the inferolateral contour. Marked scar retraction was also evident. At her 5-year fol-
low-up, we modified the capsular fibrotic tissue through fat grafting into a softer tis-
sue, which led to complete morphologic and clinical recovery.

In this patient, breast reconstruction with a prosthesis after a quadrantectomy re-
sulted in severe capsular contracture after radiation therapy, with a significant re-
duction in breast volume, severe retraction of the residual gland in the upper quad-
rants, and scar adherence to the chest wall. The patient also had pain and restraint of
movement.
2352
Part XI  Breast Surgery
Three sessions of fat grafting, every 4 months, led to a marked reduction of the gen-
eral retraction, and restoration of the volume deficit and natural ptosis. The recon-
structed breast became soft and pain free. The implant was not replaced.

This young woman underwent total breast reconstruction with a breast implant. No
radiation therapy was performed. Localized capsular contracture in the superome-
dial and inferolateral quadrants affected the cosmetic result. Two fat grafting sessions
(80 cc and 120 cc, respectively) were performed to correct gaps and restore contours.
The antifibrotic effects of fat grafting allowed resolution of the initial marked cap-
sular contracture, scar retraction, and volumetric deficit.
2353
Chapter 65  Fat Grafting to Treat Capsular Contracture
Before fat grafting
After session 1
After session 2

This patient had undergone bilateral augmentation and developed significant cap-
sular contracture in the right breast, with a round constriction of the breast and re-
traction most evident in the inferior pole. Selected capsulotomies and capsulectomies
had not improved the clinical picture. Three fat grafting sessions with 4 months be-
tween each session were necessary to restore shape, volume, and symmetry with the
contralateral breast.
2354
Part XI  Breast Surgery
Before fat grafting
After session 1

Fat grafting progressively improves the softness of the breast; the contracture, par-
ticularly evident in the upper quadrants, became a wider, rounder shape, and ptosis
was increased, allowing the breast to shift downward with a much more natural look.
2355
Chapter 65  Fat Grafting to Treat Capsular Contracture
After session 2
After session 3

In cosmetic surgery, capsular contracture is a distressing complication after breast
augmentation. This patient developed severe capsular contracture after a bilateral
submuscular augmentation in which monolumen cohesive silicone gel textured im-
plants were placed. The patient underwent surgery twice for capsulectomy and re-
placement of the implants, with no favorable result and a subsequent recurrence.
The MR scans indicate the clinical picture before fat grafting.
The patient underwent three fat grafting sessions to reduce contractures and restore
normal, stable breast contours. Her long-term results are shown 7 years after the
third fat grafting session.
2356
Part XI  Breast Surgery

The therapeutic efficacy of fat grafting is based on the regenerative potential of mes-
enchymal adipose-derived stem cells and has proved to be extremely effective and re-
liable in the treatment of many different problems, exhibiting a common etiopatho-
genesis of chronic ischemia. Nevertheless, in some clinical cases characterized by
initial major damage, particularly the severe adverse effects of radiation therapy, fat
grafting does not correct the problem and implant removal is necessary, as can be
seen in this patient who had implant extrusion after a nipple-sparing mastectomy
and intraoperative radiation therapy (IORT). Surgical removal of the implant was
accompanied by a first fat grafting session.
2357
Chapter 65  Fat Grafting to Treat Capsular Contracture

Even in unfavorable cases, fat grafting offers alternative solutions, such as total au-
tologous implant-free breast reconstruction. The patient is shown 45 days after im-
plant removal and her first and second fat grafting sessions.
2358
Part XI  Breast Surgery
After removal of implant and session 1
After session 2

The same patient’s results are seen after her third and final fourth sessions of fat
grafting.
2359
Chapter 65  Fat Grafting to Treat Capsular Contracture
After session 3
After session 4

Clinical Caveats
 The adipose-derived stem cells (ASCs) contained in lipoaspirates modify the fibrotic
and ischemic tissue of capsular contracture into soft tissue with restored micro-
circulation.
 Tissue regeneration induced by fat grafting leads to a restoration of normal breast
morphology.
 Uniformity of tissue deposition can be optimized by using preoperative computer-
assisted planning tools and intraoperative navigation systems.
 Harvesting and purification of fatty tissue (centrifugation) are straightforward
processes.
 Fat tissue deposition is performed between the skin and the capsule in multiple
sessions with a 3- to 4-month interval.
 Three to six sessions are generally required to obtain stable, long-lasting results.
2360
Part XI  Breast Surgery
Annotated Bibliography
Embrey M, Adams EE, Cunningham B, et al. A review of the literature on the etiology of
capsular contracture and a pilot study to determine the outcome of capsular contrac-
ture interventions. Aesthetic Plast Surg 23:197-206, 1999.
This review covers the literature on several proposed contracture factors, including filler
material, implant placement, surface texture, and bacterial infection. The pilot study’s
goal was to test the feasibility of a data collection form that could be used in a scaled-up
study to analyze multiple surgeons’ records. The goal of the expanded version of this
study will be to determine the efficacy of available interventions for capsular contrac-
ture, including surveillance.
Kronowitz SJ, Robb GL. Radiation therapy and breast reconstruction: a critical review of
the literature. Plast Reconstr Surg 124:395-408, 2009.
The optimal timing and technique of breast reconstruction in patients who may require
postmastectomy radiation therapy are controversial. Even with the latest prosthetic ma-
terials and modern radiation delivery techniques, the complication rate for implant-
based breast reconstruction in patients undergoing postmastectomy radiation therapy
is more than 40%, and the extrusion rate is 15%. They conclude that in patients who
will receive or have already received postmastectomy radiation therapy, the optimal ap-
proach is delayed autologous tissue reconstruction after postmastectomy radiation ther-
apy. If postmastectomy radiation therapy appears likely but may not be required,
delayed-immediate reconstruction may be considered.

Patete M, Riboldi M, Spadea MF, et al. Motion compensation in hand-held laser scanning
for surface modeling in plastic and reconstructive surgery. Ann Biomed Eng 37:1877-
1885, 2009.
The authors report on the development of a new integrated method for breast mor-
phology assessment in plastic and reconstructive surgery comprising hand-held laser
scanning with active compensation of breathing motion and involuntary movements to
obtain a thorough, artifact-free representation of patient breast shape. This was ob-
tained by tracking surface motion with a configuration of passive markers fitted on the
patient’s thoracoabdominal region. The proposed method, based on a mapping proce-
dure, has been compared with respiratory gating, which is commonly used in radiation
therapy and biomedical imaging applications. The results show that the implemented
procedure is able to compensate for motion, resulting in quantitative surface descrip-
tion to be used for clinical evaluation.
Rigotti G, Marchi A, Galiè M, et al. Clinical treatment of radiotherapy tissue damage by
lipoaspirate transplant: a healing process mediated by adipose-derived adult stem cells.
Plast Reconstr Surg 119:1409-1422, 2007.
The objective of this study was to assess the presence of adipose-derived adult stem cells
left in their natural scaffold in the purified lipoaspirate and to assess the clinical effec-
tiveness of lipoaspirate transplantation in the treatment of radiation side effects. This
study was designed beginning with surgical procedures in 2002 and envisaging a con-
tinuous patient follow-up to 31 months. Twenty consecutive patients undergoing ther-
apy for side effects of radiation treatment with severe symptoms or irreversible function
damage (LENT-SOMA scale grade 3 and 4) were enrolled. Purified autologous lipoaspi-
rates (60 to 120 cc) taken from a healthy donor site were administered by repeated min-
imally invasive computer-assisted injections. This study demonstrates that this surgical
procedure is an effective therapeutic approach for resolving the late side effects of radi-
ation therapy. According to the proposed hypothesis of the ischemic nature of radio -
lesions, treatment with lipoaspirate transplantation is potentially extended to other forms
of microangiopathies.
Rigotti G, Marchi A, Sbarbati A. Adipose-derived mesenchymal stem cells: past, present, and
future. Aesthetic Plast Surg 33:271-273, 2009.
The authors report on the history, current use, and expected future developments of
adipose-derived mesenchymal stem cells technology in fat grafting.
Suggested Readings
Marques M, Brown SA, Oliveira I, et al. Long-term follow-up of breast capsule contracture
rates in cosmetic and reconstructive cases. Plast Reconstr Surg 126:769-778, 2010.
Whitfield G, Horan G, Irwin M, et al. Incidence of severe capsular contracture following
implant-based immediate breast reconstruction with or without postoperative chest wall
radiotherapy using 40 Gray in 15 fractions. Radiother Oncol 90:141-147, 2009.
2361
Chapter 65  Fat Grafting to Treat Capsular Contracture

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Augmentation Mastopexy

DENNIS C. HAMMOND
CHAPTER 66

A
ugmentation mastopexy is generally regarded as one of the most challenging
of all the aesthetic procedures performed on the breast. This reputation is well
deserved because of the thoughtfulness required in designing an appropriate opera-
tive strategy and the technical expertise required to perform the procedure. For many
patients presenting with ptosis and volume loss, operative correction is more of a re-
constructive endeavor than a purely aesthetic one. Thus revisions are often required
to obtain an optimal result. This does not indicate that the overall procedure is a fail-
ure, but rather is a consequence of handling multiple surgical variables at once. It is
with this philosophy in mind that I will outline the principles that govern the design
of a successful operative strategy and describe the factors that influence specific im-
plant choice as well as the technique of skin envelope management.
Indications
An aesthetic breast represents a harmonious positional relationship between the foot-
print of the breast and the location of the nipple-areola complex. When the nipple-
areola complex is located in any inferiorly displaced position other than at or slightly
above the point of maximal projection of the breast mound, it is considered ptotic.
This is not the appearance of an aesthetic youthful breast, the artistic ideal that we
strive for. In this context it must be recognized that ptosis of the nipple-areola com-
plex is not an all-or-none phenomenon; varying degrees of nipple-areola complex
ptosis can occur. Other variables can affect how the nipple-areola complex position
is perceived, including the location of the breast footprint on the chest wall and the
presence of pseudoptosis or ptosis of the breast parenchyma and skin envelope in
association with a normally positioned nipple-areola complex.
With this in mind, one strategy that can be used to guide a ptosis correction proce-
dure is the location of the nipple in relation to the location of the inframammary
fold. When viewed from directly in front, a line can be drawn across the chest con-
necting the inframammary fold from side to side. If the nipple is located 2 cm or
more above this line, simple breast augmentation will provide enough lift to prop-
erly position the nipple-areola complex at the apex of the breast mound.
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Part XI  Breast Surgery

In these cases, if the nipple-areola complex position is still a bit low, the inframam-
mary fold can be lowered slightly to reposition the implant below the nipple-areola
complex to create the proper nipple-areola complex–to–breast mound relationship
and optimize the aesthetic result. Between 0 and 2 cm above the fold, a periareolar
mastopexy may be required to create the best result.
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Chapter 66  Augmentation Mastopexy
Again, lowering the fold may be helpful in bringing all the elements of breast shape
and proportion into harmony to create the best result. For patients with nipples that
fall below the inframammary fold line, in addition to a periareolar technique, a ver-
tical extension will likely be needed to completely correct the ptosis.
This is an example of a patient who presented
for breast augmentation with a normal nipple
position. For this woman, a simple breast aug-
mentation can be performed, and the implant
and the nipple will be positionally in phase,
creating a pleasing result.
This is an example of a patient whose nipples
are located just above the level of the infra-
mammary fold. For this woman, the optimal
result will be obtained by using a periareolar
lift in conjunction with placement of an im-
plant.
This is an example of a patient whose nipples
are located well below the inframammary fold.
The skin envelope is loose and redundant. For
this woman, a circumvertical mastopexy pat-
tern can effectively lift the nipple-areola com-
plex the required amount and help to manage
the redundant skin envelope.

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Part XI  Breast Surgery
Contraindications
Aside from the purely technical aspects of treating breast ptosis are the concerns pa-
tients have regarding the scars that are produced. In particular, for patients who are
on the borderline of requiring a periareolar procedure to optimize the aesthetic re-
sult, concerns about the periareolar scar may prompt the surgeon to try a different ap-
proach. In these patients lowering the fold slightly may allow a reasonable result
without the need for a periareolar procedure. It may also be helpful to use an anatom-
ically shaped cohesive gel implant that concentrates more of the volume in the infe-
rior pole of the breast.
This 40-year-old woman requested breast augmentation. She was unwilling to ac-
cept the scars associated with a periareolar mastopexy; therefore an anatomically
shaped cohesive gel implant was used to concentrate more of the implant volume in
the lower pole of the breast and limit the likelihood of any excess upper pole full-
ness. She is shown 4 years after the placement of a 375 cc anatomically shaped co-
hesive textured silicone gel implant; the skin envelope has been filled without any
excess upper pole distortion. The shape of the breast is acceptable; however, the po-
sition of the nipple falls just below the point of maximal projection of the breast
mound. For this patient, this was an acceptable compromise, given the fact that there
was no periareolar scar.

If patients are advised preoperatively that the nipple-areola complex may still ap-
pear a bit low after surgery, this may be an acceptable option if the goal is to avoid
the periareolar scar. One maneuver that carries a significant potential for postoper-
ative dissatisfaction is an attempt to lift the nipple-areola complex by using an overly
large implant.
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Chapter 66  Augmentation Mastopexy
This 24-year-old woman is shown 1 year after an 800 cc smooth round silicone gel
implant was placed in an attempt to avoid the need for a mastopexy. Although the
larger volume device was placed in an attempt to “lift” the breast, all that has been
accomplished is the creation of an overly large and out-of-proportion breast that
still has a nipple-areola complex that is too low.
This strategy is often unsuccessful in lifting the nipple-areola complex the needed
amount and leaves the patient with a breast that is too large, with sharp, unnatural
contours. The negative effects of such large devices on the patient’s soft tissues over
time make this an unattractive option in nearly every circumstance. For these rea-
sons, the strategy of using a large device in an attempt to lift the nipple-areola com-
plex and avoid the need for a formal mastopexy should be avoided.
Operative Strategy: To Stage or Not to Stage
It has been suggested that one technique that can be used to improve the outcome
of an augmentation mastopexy is to stage the procedure by breaking it up into its
two component parts. Generally speaking, this involves performing the mastopexy
first, followed later by the addition of an implant. The advantage of this approach is
that the control the surgeon has over the final result is enhanced by dealing with only
one set of variables at a time. By successfully reducing the surface area of the redun-
dant skin envelope, normalizing the position and size of the nipple-areola complex,
and letting the final result stabilize over time, more reliable decisions can be made about

the size, shape, and position of the subsequent implant. The disadvantage of this ap-
proach is that two procedures are required to achieve the end result, and if any com-
plications develop, a third or even a fourth procedure could be required to achieve
an acceptable endpoint. In addition, the financial strain placed on patients using this
approach can be significant, leading many patients to abandon the idea altogether. To
achieve a reasonable result after the first-stage mastopexy, a significant skin tighten-
ing will likely be required that can restrict the size of the implant that is chosen dur-
ing the augmentation. To perform the procedure in the reverse—that is, to place the
implant first and then perform the mastopexy later—is an even less attractive op-
tion, since it is very likely that a properly placed implant will ride high compared
with the ptotic breast during healing after the augmentation procedure. Thus a tem-
porary but potentially distressing deformity can be created that must be tolerated
until the mastopexy is completed.
To avoid these disadvantages, many surgeons perform the augmentation mastopexy
as one procedure at the first operation. By intelligently adding an appropriate-sized
implant and then tightening the skin envelope around this newly created breast, ex-
cellent results can be obtained. If a revisionary procedure is required in the future,
it is usually of less magnitude and complexity than would generally be required when
using a staged approach. For this reason many surgeons prefer to combine the aug-
mentation with the mastopexy in one operation, accepting the possibility that a re-
visionary procedure may be necessary in the future.
It has been suggested that one of the reasons that augmentation mastopexy is so dif-
ficult is that the technical details of the operative strategy work against one another.
In other words, adding an implant enlarges the breast volume and performing the
mastopexy reduces the skin envelope, two factors that when taken to excess can com-
pete with each other. It is perhaps more accurate to think of the procedure as en-
larging the breast volume the correct amount to allow the still-redundant skin en-
velope to be reduced to match the new breast volume, thus creating a situation in
which the implant and the breast work together to just the proper degree to create
an aesthetic breast shape. To achieve such a result requires technical skill and artistry,
which for the surgeon is one of the most compelling aspects of the procedure.
Implant Selection
When selecting an implant for an augmentation mastopexy patient, there are slightly
different variables involved than those for a simple breast augmentation. First, for
many patients with breast ptosis, the skin envelope has been compromised to the
point that it has little normal “rebound” under stretch, even after it has been tight-
ened by removing the redundant skin. As a result, the implant is not held in position
as tightly as in a breast augmentation patient, where the surrounding soft tissues can
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