Phẫu Thuật Tạo Hình Đường Nét Cơ Thể Và Hút Mỡ (Body Contouring and Liposuction)

40
PART | 2  Upper extremity contouring
FIG. 6.9  Bolster dressing in place at end of procedure helps to recre­
ate axillary fold.
FIG. 6.10  (A–D) Views of 63-year-old woman before surgery and 4 months postoperatively.
A
B
3. Wash surgical area 24 hours after surgery unless bolster
dressing is in place. In those cases, area should be kept
dry until bolster is removed, normally in 2 to 4 days.
4. Use Purell® or similar waterless sanitizer or rubbing
alcohol four times a day on incision sites.
5. Do not raise elbows above level of shoulders for 3
weeks.
6. After 3 weeks, begin active (no passive therapy) eleva­
tion of arms.
COMPLICATIONS
Complications in a series of 650 cases have included two
infections, both of which responded to conservative antibi­
otic therapy. In 8% of patients small wound separations
(1–2 cm) occurred, usually after 14 days. All healed by
secondary intention after wet-to-dry dressings and topical
antibiotic ointments.
Two complete wound dehiscences; both after an arm
was fully extended above the shoulder, occurred at 7 and
10 days post operation. These were corrected on the days
of the injuries and went on to uneventful, satisfactory
healing.
In 10% of patients, hypertrophic or unacceptable scar­
ring occurred. All revisions on nonacute surgical complica­
tions are carried out at 1 year.
There may be bow-stringing or “bat wing” deformity
secondary to tension. This is treated with a Z plasty or other
skin lengthening technique with scar release. We use bolster

41
Chapter | 6  Limited scar brachioplasty
dressings for 3–5 days. The more commonly seen presenta­
tion is bow-stringing or “bat wing” deformity secondary to
distraction or separation of the axillary skin from the base
of the wound. One can check for distraction by seeing how
easily the involved area of skin can be pushed up into the
axillary hollow. This is treated with scar excision only.
Place sutures for the bolster dressing and tack the edges of
the wound to the axillary base in line with the axillary fold.
Close the incision and leave the bolster dressing in place
for 3–5 days. The bow-string deformity is not uncommonly
seen in patients with macromastia or heavy pendulous
breasts. For these patients, wearing a good, supportive bra
will lessen or eradicate the bow-string presentation. A
reduction mammoplasty should also be considered. It is
important to recognize this phenomenon and discuss these
options with the patient during the initial consultation.
No hematomas or seromas were observed. No neuro­
vascular, lymphatic, or musculoskeletal problems occurred.
CONCLUSION
The minimal incision transaxillary brachioplasty should be
the procedure of choice for all those patients requesting
recontouring and rejuvenation of the upper arm who do not
have excessively dependent dermatolipodystrophy. Please
refer to Figs 6.10–6.14 for a representative selection of
before and after surgery results. It is a simple procedure that
delivers predictably good results, comparable to those
results achieved with the traditional approach, while confin­
ing the scar to the axillary area.
FIG. 6.11  (A, B) Views of 47-year-old woman before surgery and 6
months postoperatively.
A
B
C
D
FIG. 6.10  Continued

42
PART | 2  Upper extremity contouring
FIG. 6.12  (A, B) Views of 32-year-old woman before surgery and 11
months postoperatively.
A
B
FIG. 6.13  (A, B) Views of 43-year-old woman before surgery and 5
months postoperatively.
A
B
FIG. 6.14  (A, B) Views of 43-year-old woman before surgery and 5
months postoperatively.
A
B
REFERENCES
1. Pollock WJ, Virnelli FR, Ryn RF. Axillary hidradenitis suppurativa:
a simple and effective surgical technique. Plast Reconstr Surg
1972;49:22–7.
2. Correa-Iturraspe M, Fernandez JC. Dermolipectomia braquial. Prensa
Med Argent 1954;41:2432.
3. Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast
Reconstr Surg 1998;102:545–51; discussion 552–3.
4. Abraham DL. Minibrachioplasty: minimizing scars while maximizing
results. Aesth Surg J 2003;114:1631–8.
5. Richards ME. Reassessing minimal incision brachioplasty. Aesth Surg
J 2004;25:175–9.
6. Richards ME. Minimal incision brachioplasty: a first choice option in
arm reduction surgery. Aesth Surg J 2001;21:301–10.
7. Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: tech­
nical refinements in upper arm contouring. Plast Reconstr Surg
2008;121:305–7.
8. Reed LS, Hyman JB. Minimal incision brachioplasty: refining trans­
axillary arm rejuvenation. Aesth Surg J 2007;27(4):433–41.

43
© 2013 Elsevier Inc
Chapter 7 
Key Points
●
Fat harvesting should be done with maximum care
and minimal negative pressure to prevent damage to
the fat cells.
●
Patient selection and education to manage
expectations will maximize patient satisfaction.
●
The fat should be injected in multiple layers to prevent
pooling and cyst formation.
●
The use of 3D imaging will help to quantify the
pre- and post-injection breast volume. This will help to
measure the fat survival percentage.
●
Fat harvested from different donor sites should be
mixed before injection to have a similar fat cell
population in both breasts.
Fat grafting to the breast
Kamran Khoobehi
INTRODUCTION
Autologous fat grafting is a well-established technique that
is practiced by many plastic surgeons. Fat cell abundance
and ease of harvesting make fat grafting a logical choice
for soft tissue defect restoration and augmentation. The
technique of fat grafting varies from surgeon to surgeon,
and there are no standardized harvesting, preparation and
injection techniques.
The current popularity of fat grafting, in many ways, is
because of the work done by Dr. Sydney Coleman. He
popularized the technique for harvesting the fat using a
handheld syringe and centrifuging for compaction.1
The need for large volume fat harvesting and injection
could not be met by the current techniques due to the length
of time needed to harvest fat and centrifuge the fat. The
average time for harvesting, processing and injecting fat by
the Coleman technique is 100 cm3 of fat in 1 hour.2
HISTORY OF FAT GRAFTING
The history of fat grafting goes back to 1893 when Neuber
used it for facial defects.3 In 1895, Czerney used fat grafting
for chest wall deformity post mastectomy.4 The early exper­
imentation with fat grafting was not popular because, at a
time when little was known about tumescent liposuction,
most fat harvesting was performed by excision. The use of
tumescent liposuction has given us the ability to harvest
large amounts of fat with minimal donor site morbidity.
In 1987, Mel Bircoll published his work on fat grafting
to the breast.5,6 The shortcomings of his work were poor
long-term follow-up and a lack of mammographic studies
as indicated by letters to the editor from 1987.7 American
Society of Plastic Surgeons (ASPS) published a position
paper in 1987 “Deploring the use of fat injection in breast
augmentation” due to the fear of interference with breast
cancer detection.8 The main concern at that time was that
calcification from necrotic fat would cause interference
with breast tissue evaluation by mammogram. At the same
time published papers stated that surgical procedures such
as breast reduction,9,10 augmentation11,12 and any breast pro­
cedure can also cause calcification. Further studies indi­
cated that calcification from fat necrosis is easily
distinguished from breast cancer calcification.13–20
There was a long gap before any work was published
on fat grafting to the breast. Dr. Coleman published his
work on fat grafting to the breasts in 2007. His results were
remarkable and showed long-term survival of the injected
fat.2
In 2007, ASPS and The American Society for Aesthetic
plastic surgery (ASAPS) jointly and strongly supported the
ongoing research efforts that would improve the safety and
efficacy of the procedure21 but also cautioned against fat
grafting for breast augmentation.
The future of fat grafting depends on the establishment
of a standardized harvesting, processing, injection tech­
nique, long-term follow up for safety and efficacy, and also
establishment of a data base for all the fat grafting patients.
PRINCIPLE OF LOW PRESSURE
FAT HARVESTING
Handheld syringe aspiration is accepted as a gentler tech­
nique for fat harvesting. There are no published data to
For additional online content visit

Part 3  Breast reshaping

44
PART | 3  Breast reshaping
support this claim. We at LSU division of Plastic and
Reconstructive Surgery undertook the study to find out the
negative pressure that is generated by handheld syringes
and liposuction machines. The graph in Fig. 7.1 shows the
in-situ maximum pressure within the 1, 3, 5, 10, 30 and
60 cc syringes. Negative pressures were measured in vitro
and in situ with 1, 2, 3, and 10  cc pull on a 10 cc Luer-Lock
syringe as well as a conventional liposuction machine at
254 mmHg, 381 mmHg, and 762 mmHg (Figs 7.1, 7.2, and
7.3).
The graph in Fig. 7.2 shows the negative pressure pro­
duced in a 10 cc syringe to be as high as 660 mmHg with
full pull and 280 mmHg with only 1 cc pull on the 10 cc
syringe.
The constant negative pressure at the low setting
(254 mmHg) by a liposuction machine is 220 mmHg. This
is less than the negative pressure in a 10 cc syringe only
pulled back 1 cm3. Most liposuction machines have a
control for adjusting the negative pressure.
FIG. 7.1  The graph shows the in-situ maximum pressure within the
1, 3, 5, 10, 30, and 60 cm3 syringes.
1
3
5
10
30
60
0
100
200
300
400
500
600
700
800
cc syringe
mm/Hg
FIG. 7.2  The graph shows the negative pressure produced in a
10  cm3 syringe to be as high as 660 mmHg with full pull and
280 mmHg with only 1  cm3 pull on the 10  cm3 syringe.
1cc
2cc
3cc
10cc
0
100
200
300
400
500
600
700
mm/Hg
FIG. 7.3  Negative pressure measurements for liposuction machine
at different setting in situ.
Low (-10)
Med (-15)
High (-30)
0
100
200
300
400
500
600
700
800
Inch/Hg
mm/Hg
FIG. 7.4  Basis of fat grafting – biochemical markers.
Low
liposuction
10cc
syringe
60cc
syringe
0
1500
1000
500
mg/dl
LDH
Trigylceride
In order to evaluate the extent of damage to fat cell
caused by all harvesting techniques, lipoaspirant samples
were analyzed using lactate dehydrogenase (LDH) and tri­
glyceride levels (Fig. 7.4). Glucose-3-phosphodiesterase
(G3PD) assay was used to measure cell viability (Fig. 7.5).
LDH and triglyceride are intracellular components and
their presence in the aspiration fluid indicates cell damage
and cell wall disruption. The results suggests that the
samples harvested with the low negative pressure liposuc­
tion machine were lower in LDH and triglycerides. The
G3PD assay suggests cell viabilities were high in samples
from the low-pressure liposuction machine in comparison
to the handheld syringe, which indicates more viable cells
by the low pressure technique.
Harvested fat cells were stained with fluorescent dyes
for imaging using scanning electron and confocal laser
electron microscopes (Fig. 7.6). The slides show the outer
cell layers bursting from the negative pressure.
FIG 7.6 APPEARS ONLINE ONLY

44.e1
Chapter | 7  Fat grafting to the breast
FIG. 7.6  Basis of fat grafting – microscopic analysis.
Low pressure liposuction
60 cc syringe lipoaspiration

45
Chapter | 7  Fat grafting to the breast
FIG. 7.5  Assessment of viability – G3PD activity.
Low
liposuction
10cc
60cc
Coleman
0
5
10
15
20
25
30
35
34.05
27.32
15.49
17.69
The low-pressure liposuction method removes the
human factor and variation of the pull on the syringe and
provides consistent negative pressure that helps to decrease
operating room time and also prevents the surgeon’s hand
fatigue. This technique yields large volumes of fat in a short
period of time and minimizes the damage to the fat cells.
AUTOLOGOUS FAT GRAFTING
TO THE BREAST
In June 2008 at Louisiana State University Health Science
Center in New Orleans, we started an IRB approved study
on fat grafting to the breast. So far we have had more than
276 patients in this study and collection of the data has
started for the follow up studies. Currently, fat grafting to
the breast is a treatment option in conditions such as micro­
mastia, breast ptosis, post mastectomy breast reconstruc­
tion, asymmetric breast, congenital malformation of the
breast, and for treatment of complications associated with
implant augmentation mammoplasty.
Technique
Harvesting
Local Infiltration
The solution that is used is 20 cm3 of lidocaine 1% with
epinephrine, plus 2 cm3 epinephrine 1/1000 in 1 liter of
lactated Ringer. The volume of tumescence is 10–20%
more than the aspirate. It is imperative to wait 20 min. post
infiltration to maximize vasoconstriction and minimize
blood loss.
Cannulae
A blunt 5 mm Mercedes tip cannula is used for harvesting
the fat. The common belief is that a large cannula will
damage the donor site, but our experience with large
cannulae has been the opposite. The other belief is that
a large cannula will produce large particles of fat, which
will make it hard to reinject with a small cannula (11
gauge) but our experience also has been contrary to current
belief.
Fat Cell Preparation
The process of centrifugation increases the risk of contam­
ination and cell damage. One advantage of centrifugation
is to compact the fat cells. Another advantage of centrifu­
gation is the ability to separate damaged cells from intact
cells. Centrifugation at a low speed for a short period
(100 g/30 s) will give the same compaction as a higher
speed and longer period (1400 g/3 min). Refer to Fig. 7.7.
The other observation is the lack of oil on the top of the
syringe with low pressure fat harvesting. This observation
is consistent with our study showing that the fat cells har­
vested by low pressure are damaged less, and less oil leaks
out.
The drawback of not centrifuging the fat is overestima­
tion of the amount of actual injected fat. We adjust the
actual injected fat by 20% to correct for this if we do not
centrifuge the fat before injection.
Fat Injection
After the fat has been decanted, the fluid in the bottom
of the jar is discarded and the fat cells transferred to
30 cm3 syringes and then from 30 cm3 to 10 cm3 syringes
with a male-to-male connecter. Fat cells are then injected
in a multilayer technique while withdrawing. Each 10 cm3
syringe will require at least five to seven passes to
finish. The cannula for injection is an 11 gauge blunt tip
single-side port cannula. A double-sided port causes trap­
ping of the ligaments and clogging. Injection is started in
the submuscular plane, then at the subcutaneous layer and
finally, the subglandular planes.
FIG. 7.7  The picture shows the lack of free oil on the top after cen­
trifugation at 100 g and 1500 g.

46
PART | 3  Breast reshaping
POSTOPERATIVE CARE
In our practice the recovery from fat grafting is fast and
much less painful than with implant breast augmentation.
Most patients complain more about the donor site than the
breast pain. There is usually swelling that resolves in a few
weeks. The breast volume will finalize at 3 months post
injection. Massaging of the breast is discouraged during the
first few days to prevent pooling of the fat.
Our experience with patient satisfaction has centered
around long-term volume retention. Most patients are con­
cerned about the loss of volume. The use of 3D imaging,
patient education and also consistent photographic docu­
mentation is a must. Patients emphasizing the size rather
than the quality of the result are not good candidates for fat
grafting.
FAT GRAFTING FOR IMPLANT FAILURE
The use of the implant for breast augmentation is the
accepted treatment that works well in the majority of
patients. Complications from augmentation include capsu­
lar contracture, rippling, bottoming out, infection, palpable
implants, visible implants, and an unsatisfactory shape and
size. The use of silicone gel has helped in certain patients
to decrease rippling and palpable implants. For patients that
do not want implants anymore, or have failed with these
treatments, fat injection is an alternative.
For patients with saline implants, these are deflated
under local anesthesia 2 weeks before the planned surgery
to give the tissue time to contract (Fig. 7.8B, C). Figure 7.9
shows the same patient 2 weeks later. The amount of tissue
retraction and improvement is impressive.
FIG 7.8B, C, 7.9, 7.10, 7.11 APPEARS ONLINE ONLY
The mammograms before explantation show minimal
breast parenchyma visualization and blockage of the breast
tissue by the implant. In mammograms after explantation
and fat grafting, full breast tissue can be evaluated. Figures
7.12 and 7.13 show mammograms before and 1 year after
fat grafting.
FIG 7.13 APPEARS ONLINE ONLY
FAT GRAFTING IN CONJUCTION
WITH MASTOPEXY
The aim of any mastopexy operation is repositioning of a
sensate and viable nipple to an esthetically pleasing point
on the breast mound with minimal scars and augmentation
or creation or improvement of upper pole fullness with
minimal scars. Therefore, the ideal approach to rejuvenate
and lift the breast requires the surgeon to address the issue
of simultaneous volume augmentation. The concept of a
single stage mastopexy with implant augmentation is an
attractive concept but raises debates amongst most plastic
surgeons.22 The complications are attributed to the contra­
dicting forces that the breast parenchyma is subjected to
during an augmentation/mastopexy, along with the altera­
tion in the architecture of the breast and the blood supply
to the mammary tissue and its nipple–areola complex. The
complications range from dehiscence, poor scarring, recur­
rent ptosis, areola asymmetry, nipple ischemia, deflation,
capsular contracture, misplacement, and infection. In fact,
Spear et al reported a complication rate of 17.4% with a
revision rate of 8.7% for primary augmentation/mastopexy
in his 3-year review. Another recent publication reported a
complication rate of 10.6% with a revision rate of 14.6%
for augmentation/mastopexy over a 14-year period.23
Preoperative Preparation
Patients are instructed to not gain or lose weight before
surgery. All patients are prepped with antibacterial soap the
FIG. 7.12  Mammogram before and one year after implant removal and
fat grafting.
FIG. 7.8  For patients with saline implants the implants are deflated
under local anesthesia 2 weeks before the planned surgery to give the
tissue time to contract.
A

46.e1
Chapter | 7  Fat grafting to the breast
A preoperative mammogram, 3D imaging and photo­
graphs are obtained on all patients as well as a postoperative
mammogram and 3D imaging a year after the surgery.
Patients follow the American Cancer Society guidelines for
follow up breast cancer screening.

46.e2
PART | 3  Breast reshaping
FIG. 7.8  For patients with saline implants the implants are deflated under local anesthesia 2 weeks before the planned surgery to give the
tissue time to contract.
B
C
During the surgery the fat graft is performed first and
then the deflated implant is removed and a drain placed in
the pocket. The protocol is different for patients with saline
implants (Fig. 7.10) vs. silicone gel implants (Fig. 7.11).
For silicone gel implants, I would remove the implants and
capsule first with limited fat grafting to prevent fat collec­
tion in the explanted implant pocket. The final fat grafting
is performed 3 months later.
Furthermore, superior pole fullness is usually lacking in
the majority of patients undergoing this procedure and post­
operative “bottoming out” of the implant is a common
long-term problem. In order to avoid the use of implants
with mastopexy, multiple procedures are reported in the
literature utilizing various flaps to provide superior pole
fullness along with repositioning of the nipple and tighten­
ing of the skin envelope.

46.e3
Chapter | 7  Fat grafting to the breast
FIG. 7.9  (A) Patient 5 years post saline breast augmentation by
another surgeon. (B) Immediate post saline implant deflation under
local anesthesia. (C) 2 weeks post deflation only.
A
B
C

46.e4
PART | 3  Breast reshaping
A
B
FIG. 7.10  (A) Sub glandular saline implant. (B) Immediate post
deflation. (C) 1 year post one session of fat grafting (R 350 cc and
L 430 cc).
C

46.e5
Chapter | 7  Fat grafting to the breast
FIG. 7.11  (A) Patient 25 years after silicone gel breast augmentation,capsular contracture and implant rupture. (B) One year post implant
removal and fat grafting (R 267cc and L 280 cc) in one session.
A
B
FIG. 7.13  Mammogram before and 1 year after fat grafting.

47
Chapter | 7  Fat grafting to the breast
7.17 & 7.18). Parenchymal suspension is performed by
suturing lateral breast tissue to the lateral edge of the pec­
toralis muscle.
FIG 7.17, 7.18 APPEARS ONLINE ONLY
Volume augmentation with autologous fat grafting obvi­
ates the need for the creation of a pocket and circulatory
compromise to the nipple. As the fat is layered in multiple
planes and deposited in small increments, it further mini­
mizes trauma to the nipple–areola complex circulation from
the underlying blood vessels.
FAT GRAFTING FOR AUGMENTATION
There are a group of patients that do not want implants.
These patients want a more natural look and feel. We have
found that these patients tend to be older, have been
night and morning of the surgery. We require a preoperative
mammogram and postoperative mammogram 1 year after
surgery.
Surgical Technique
Fat harvesting is performed based on the described proto­
col. Fat injection is performed with a blunt 11 gauge cannula
through small 2 mm stab incisions on the medial and lateral
aspects of the breasts. Liposculpting is performed by
deploying the fat in a layering fashion into the subpectoral
and prepectoral planes as well as into the subcutaneous
planes. With each pass approximately 1–2  cm3 of fat is
deposited into the target area. All patients with congenital
tubular breasts underwent a circumareolar mastopexy, and
the remaining patients underwent a vertical mastopexy with
a small horizontal component (Figs 7.13, 7.14, 7.15, 7.16,
FIG. 7.14  (A, B & C) Preoperative marking shows the target area for fat grafting. Fat grafting is done for the upper pole and then mastopexy
is performed. (B & C) Preoperative marking shows the target area for the fat grafting. Fat grafting is done for the upper pole and then mas­
topexy is performed.
A
D
B
C

47.e1
Chapter | 7  Fat grafting to the breast
FIG. 7.17  Pre and post mastopexy and fat grafting 9 months post mastopexy. Right 405 cm3, left 400 cm3.
A
B
A
B
FIG. 7.18  Pre (A) and post (B) abdominoplasty, mastopexy, and fat grafting 6 months postoperative. Right 230 cm3, left 270 cm3.
The placement of the fat into the subpectoral and sup­
rapectoral planes in the superior pole of the breast helps to
maintain the transplanted fat in the area that is most desired
and least addressed by other methods. The cleavage area
can be enhanced by liposculpting the breast with subcutane­
ous fat placement along the medial aspects of the breasts.
Symmetry can also be accurately addressed with precise
placement of the volume of fat grafts into the deficient
areas.

48
PART | 3  Breast reshaping
FIG. 7.15  Preoperative (A) and (B) 1 year after mastopexy and fat grafting, abdominoplasty, and liposuction. Right 710 cm3, left 710 cm3.
A
B
FIG. 7.16  Preoperative (A) and (B) 1 year after mastopexy and fat grafting, abdominoplasty and liposuction. Right 710 cm3, left 710 cm3. Total
OR time for the mastopexy, fat grafting, abdominoplasty and liposuction was 5 hours and 17 min.
A
B

49
Chapter | 7  Fat grafting to the breast
FIG. 7.20  Preoperative (A) and (B) 1 year post fat grafting. Right 570 cm3, left 500 cm3, total OR time 110 min.
A
B
pregnant, have lost the upper fullness, and most of them
want only minimal size change. Fat grafting can provide
the size and natural feel without the use of implants. The
most important thing is the emphasis on quality rather than
quantity.
Fat grafting patient education includes 3D imaging and
using software to give the patient realistic expectations
before surgery.
The pictures suggest that the greatest enhancement
are at the cleavage, an area not often enhanced by submus­
cular implants (Figs 7.19, 7.20, 7.21, 7.22 and 7.23). Full
disclosure about the risks, including cyst formation, calci­
fication, and the possible need for biopsy, is a must.
FIG 7.19, 7.23 APPEARS ONLINE ONLY
FAT GRAFTING OVER EXISTING IMPLANTS
For patients that are happy with their implants but want
more cleavage, less rippling and softer breasts, fat grafting
can be an option. Fat grafting can be done at the subcutane­
ous plane to give more coverage to the implants. I would
recommend that back-up implants be available, and patients
should be informed about the possibility of rupturing the
implant and the need for an implant exchange. The use of
fat grafting on the top of silicone implants should be done
with extreme caution to prevent damage to the implant
(Fig. 7.24).
FAT GRAFTING FOR BREAST
RECONSTRUCTION
The use of fat grafting for revision of breast reconstruction
(implants or autologous) post mastectomy is the most
common use of fat grafting.
Fat grafting can be used in combination with implants
for reconstruction. Implant and acellular dermal matrix can
be used at the first stage and then fat grafting later, to
enhance and add volume and soften the breast tissue. Fat
grafting has been shown to improve the radiated breast
tissue (Figs 7.25, 7.26, and 7.27).
FIG 7.26, 7.27 APPEARS ONLINE ONLY
FAT GRAFTING FOR CONGENITAL
BREAST DEFORMITIES
Patients with tubular breasts, Poland syndrome, and severe
breast asymmetry are candidates for fat grafting. The

49.e1
Chapter | 7  Fat grafting to the breast
The most common findings after the use of the free flap
for breast reconstruction are upper pole depression, volume
asymmetry, indentations, and a need for more projection.
Fat grafting can help to add volume, enhance cleavage, and
give projection and upper pole fullness.

49.e2
PART | 3  Breast reshaping
A
B
FIG. 7.19  A fat-grafted patient at 1-year postoperative. Right 200 cm3, left 200 cm3.
FIG. 7.23  Same patient as in Fig. 7.21 with view of the cleavage, 3D imaging.
A
B

49.e3
Chapter | 7  Fat grafting to the breast
A
B
FIG. 7.26  Patient with bilateral mastectomy; post bilateral DIEP flap breast reconstruction, and 6 months post fat grafting. Right 390  cm3,
left 440  cm3.
C
D
A
B
FIG. 7.27  Patient after right mastectomy, DIEP flap reconstruction and 1 year post fat grafting. Right 250  cm3.

50
PART | 3  Breast reshaping
A
B
FIG. 7.21  Preoperative (A) and (B) 6 months post fat grafting. Right 345  cm3, left 345  cm3.
A
B
FIG. 7.22  Same patient as in Fig. 7.21, 3D imaging.

51
Chapter | 7  Fat grafting to the breast
A
B
FIG. 7.25  Patient with bilateral mastectomy; post bilateral DIEP flap breast reconstruction, and 6 months post fat grafting. Right 390  cm3,
left 440  cm3.
FIG. 7.24  Fat grafting over saline implants for rippling. 6 months postoperative. Right 200 cm3, left 200 cm3.
A
B

52
PART | 3  Breast reshaping
FIG. 7.28  Patient with severe tubular breast. 9 months post fat grafting and circumareolar mastopexy. Right 420  cm3, left 470  cm3,
A
B
FIG. 7.29  3D imaging can be used for measuring the fat graft take.
A
B

53
Chapter | 7  Fat grafting to the breast
1. Under promise and over deliver.
2. Fat grafting is not a good option for patients that keep
discussing size. The best patient is the one that talks more
about quality than quantity.
3. Patients with saline implants that request implant removal
and fat grafting will need implant deflation 2 weeks before
surgery. Patients with silicone gel implants will need two-
stage surgery.
4. I always talk about second fat grafting surgery and give
patients a discount (50% off) for the second stage if the
patient wants more volume later on.
5. Postoperative care for the breast is minimal. I recommend
my patients not to massage their breasts. I treat my patients
with antibiotics after surgery for a week. I recommend
Endermologie treatment 10 days after fat harvesting and
grafting to help the donor sites. The treatment protocol is
Endermologie twice a week for 5 weeks.
6. Complications and their management. The most common
complications specific to fat grafting to the breast are cal­
cification, oil cyst formation, and nodules in the breast.
The local radiologist should be informed about the fat
grafting. The need for biopsy can be minimized if the
radiologists are aware of the changes that are common
with fat grafting. The pattern of calcification from fat graft­
ing is different than from breast cancer. The other common
complication is patient dissatisfaction with breast size. This
is a common problem with implant augmentation too.
Patient education, patient selection and realistic expecta­
tions will prevent an unhappy patient.
BOX 7.1  Optimizing Outcomes
procedure is individualized based on the physical findings.
There may be a need for the Brava System for tissue expan­
sion before fat grafting. It can also be done in combination
with a mastopexy to achieve the desired outcome.
For the patient with tubular breasts, circumareolar
mastopexy in combination with fat grafting is necessary.
In these patients there is a connection between the lower
pole of the breast and skin and pectoralis muscle that
A
B
FIG. 7.30  Patient with Poland syndrome and GAP flap post fat grafting. Right 240 cm3, left 300 cm3, total OR time 166 min.
needs to be excised. Patients with Poland syndrome may
need to have autologous breast reconstruction as the first
stage and fat grafting for result enhancement (Figs
7.28–7.31).
OPTIMIZING OUTCOMES
See Box 7.1.

54
PART | 3  Breast reshaping
A
B
FIG. 7.31  Same patient as in Fig. 7.30 with Poland syndrome.
CONCLUSION
Fat grafting has unlimited potential to be used as a soft
tissue filler and for tissue rejuvenation. The current research
on stem cells from fat is showing enormous potential
to change the medical treatments. These cells have the
potential to differentiate into any cell lines.24 Stem cells have
the promise of cure for diabetes, liver failure, cardiomyopa­
thy, arthritis, macular degeneration, and any disease that
would benefit from cell therapy. The advantage of stem cells
from fat in comparison to embryonic or bone marrow stem
cells is the ease of harvest and large amount of donor fat.
The great potential of fat grafting to the breast is as an
adjuvant to implants for breast reconstruction as well as in
cosmetic breast augmentation.
REFERENCES
1. Coleman SR. Long-term survival of fat transplants: Controlled dem­
onstration. Aesth Plast Surg 1995;19:421.
2. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety
and efficacy. Plast Reconstr Surg 2007;119:775–85.
3. Neuber F. Fettransplantation. Chir Kongr Verhandl Dsch Gesellch
Chir 1895;22:66.
4. Czerny A. Plastischer Ersatzder Brustdruse durch ein lipoma. Chir
Kongr Verhandl 1895;216:2.
5. Bircoll M. Cosmetic breast augmentation utilizing autologous fat
and liposuction techniques. Plast Reconstr Surg 1987;79:267.
6. Bircoll M, Novack BH. Autologous fat transplantation employing
liposuction techniques. Ann Plast Surg 1987;18:327.
7. Plastic & Reconstructive Surgery, February 2008, Volume 121,
Issue 2, p 701.
8. ASPRS Ad-Hoc Committee on New Procedures. Report on autolo­
gous fat transplantation. September 30, 1987.
9. Brown FE, Sargent SK, Cohen SR, et al. Mammographic changes
following reduction mammaplasty. Plast Reconstr Surg 1987;80:
691.
10. Miller CL, Feig SA, Fox JWT. Mammographic changes after reduc­
tion mammaplasty. Am J Roentgenol 1987;149:35.
11. Benjamin JL, Guy CL. Calcification of implant capsules following
augmentation mammaplasty: Case report. Plast Reconstr Surg 1977;
59:432.
12. Koide T, Katayama H. Calcification in augmentation mammaplasty.
Radiology 1979;130:337.
13. Kneeshaw PJ, Lowry M, Manton D, et al. Differentiation of benign
from malignant breast disease associated with screening detected
microcalcifications using dynamic contrast enhanced magnetic reso­
nance imaging. Breast 2006;15:29.
14. Chala LF, De Barros N, De Camargo Moraes P, et al. Fat necrosis
of the breast: Mammographic, sonographic, computed tomography,
and magnetic resonance imaging findings. Curr Probl Diagn Radiol
2004;33:106.

55
Chapter | 7  Fat grafting to the breast
15. Fischer U, Baum, F, Obenauer S, et al. Comparative study in patients
with microcalcifications: Full-field digital mammography vs screen-
film mammography. Eur Radiol 2002;12:2679.
16. Yunus M, Ahmed N, Masroor I, et al. Mammographic criteria for
determining the diagnostic value of microcalcifications in the detec­
tion of early breast cancer. J Pak Med Assoc 2004;54:24.
17. Danikas D, Theodorou SJ, Kokkalis G, et al. Mammographic find­
ings following reduction mammaplasty. Aesth Plast Surg 2001;
25:283.
18. Hogge JP, Robinson RE, Magnant CM, et al. The mammographic
spectrum of fat necrosis of the breast. Radiographics 1995;15:
1347.
19. Abboud M, Vadoud-Seyedi J, De Mey A, et al. Incidence of calcifica­
tions in the breast after surgical reduction and liposuction. Plast
Reconstr Surg 1995;96:620.
20. Mendelson EB. Evaluation of the postoperative breast. Radiol Clin
North Am 1992;30:107.
21. Gutowski KA. ASPS Fat Graft Task Force. Plast Reconstr Surg
2009;124(1):272–80.
22. Spear SL. Plast Reconstr Surg 2006;118(7S):133S–4S.
23. Spear SL, Boehmler JHIV, Clemens MW. Plast Reconstr Surg
2006;118(7S):136S–47S.
24. Behr B, Ko SH, Wong VW, et al. Stem cells. Plast Reconstr Surg
2010;126(4): 1163–71.
Fig. 7.6, 7.8B, C, 7.9–11, 7.13, 7.17–19, 7.23, 7.26, 7.27 can be found
online.
Bonus images for this chapter can be found online at

56
© 2013 Elsevier Inc
Chapter 8 
Key Points
●
Breast reduction with Vaser (ultrasound-assisted
energy) is described.
●
Scarless breast reduction is outlined.
●
The Passot breast reduction (no vertical scars)
combined with Vaser is described.
Ultrasound-assisted breast reduction
Alberto di Giuseppe
INTRODUCTION
Ultrasound energy has been applied to the adipose compo­
nent of the breast parenchyma in cases of breast hypertro­
phy in order to reduce the volume of the breast mold.
As is known, ultrasound energy was initially used by
Zocchi1–6 to emulsify fat. A special instrument, composed
of an ultrasound generator, a crystal piezoelectric trans­
ducer, and a titanium probe transmitter was utilized to target
adipocyte cells. This new technology was first applied to
body fat to emulsify only fat cells while sparing the other
supporting vascular and connective components of the cuta­
neous vascular network. More recently, Goes,7 Zocchi,1–6
Benelli8 and di Giuseppe,9–12 have started to apply this tech­
nology to breast tissue to achieve breast reduction and cor­
rection of mild to medium-degree breast ptosis.
PREOPERATIVE PREPARATION
Patient Selection
The ideal candidates for a breast reduction with ultrasound-
assisted lipoplasty (UAL) are patients with juvenile breasts,
which usually have fatty parenchyma, or patients with post­
menopausal involution parenchyma, with good skin tone
and elasticity present. Between 60 and 70% of women with
large breasts are candidates for reduction with UAL. The
preoperative assessment includes a mammographic study,
breast clinical history, evaluation of breast ptosis, and eval­
uation of the consistency of breast parenchyma.
Preoperative Mammography
Preoperative mammograms (anteroposterior and lateral
views), the so-called Ecklund view, are taken to evaluate
the nature and consistency of the breast tissue (fibrotic,
mixed or fatty parenchyma ), distribution of the fat, pres­
ence of calcifications, and areas of dysplasia or nodularity
that might necessitate further studies (Fig. 8.1). The pres­
ence of fibroadenomas, calcifications, and other suspected
or doubtful radiologic findings should be double-checked
with ultrasound and a radiologist experienced in breast
tissue resonance.
Contraindications
In the author’s study, patients with a history of breast cancer
or mastodynia were not considered and nor were those
fearful of potential sequelae from this new technique.
Furthermore, because the amount and distribution of
the breast fat is variable, not all women are candidates
for breast volume reduction with UAL. If fat and glandular
tissue are mixed, penetration of the tissue may be impos­
sible, as noted by Lejour13 and Lejour and Abboud.14 If the
breast tissue is primarily glandular, the technique is not
indicated.
Preoperative Planning
The distance from infraclavicular notch and nipple is
drawn by hand (Fig. 8.2). Circles indicate the area of major
volume to be addressed. A circle of about 5 cm diameter is
marked around the nipple.
This area is not addressed by ultrasound as it clearly
contains 90% of the breast tissue. Ultrasound energy targets
only the fatty tissue of the breast, sparing the parenchymal
components.
SURGICAL TECHNIQUE
Infiltration
Infiltration should be divided into the three different layers
of the breast: deep, intermediate, and superficial (Fig. 8.3).
For additional online content visit

Part 3  Breast reshaping

57
Chapter | 8  Ultrasound-assisted breast reduction
FIG. 8.1  Mammographic evaluation of candidates for breast reduction with the use of ultrasound-assisted lipoplasty (UAL). (A) A typical fatty
breast. This patient is an ideal candidate for UAL. (B) Fibrotic glandular tissue is a contraindication for UAL .(C) Fibrotic mixed tissue. This patient
is a candidate for UAL of the posterior upper and lower cone.
A
B
C
FIG. 8.2  Distance from infraclavicular notch and nipple: circles
indicate the area of major volume to be addressed and a circle of about
5 cm diameter is marked around the nipple.
In deeper and intermediate layers I expect a 1.5 : 1 ratio
between infiltration and aspirate; in the superficial layer I
normally infiltrate twice what I expect to extract (2 : 1 ratio).
I use blunt infiltration cannulas, as described by Klein,15
15–20 cm long.
It is essential to perform meticulous infiltration of the
superficial layers, then to wait a minimum of 15 minutes to
allow the epinephrine (adrenaline) to take effect, before
starting ultrasound.
In a total of 500 ml of infiltration, normally 400 ml are
for deeper and intermediate layers, and 100 ml are for
superficial layers.
Skin Incisions
The operation begins with the introduction of the skin pro­
tector placed at the incision site, normally placed 1 cm
below the inframammary crease. Another incision is nor­
mally placed at the axilla, at the same length.
A further incision is placed around the areola margin,
and is utilized to address the superficial layers of the upper
quadrants, if required. This skin port is designed to protect
against friction injuries by the probe during its continuous
movement.
The fatty breast is emulsified in the lateral and medial
compartments, the upper quadrants and the inferior
aspect of the periareolar area. All the periareolar area,
where most of the glandular tissue is localized (5 cm
circumference around the nipple–areola complex), is
preserved.
Two 1.5–2.0 cm stab incisions, one at the axillary line
and the other 2 cm below the inframammary crease, are
made to allow entrance of the titanium probe.

57.e1
Chapter | 8  Ultrasound-assisted breast reduction
The deep portion is also emulsified, allowing the breast
mold to regain a natural shape through upward rotation,
thus increasing the elevation from its initial position, taken
from the midclavicular notch. Up to 4 cm of elevation is
obtained after proper reduction and stimulation to allow
skin retraction and correction of the ptosis.

58
PART | 3  Breast reshaping
BOX 8.1  Four Different Probe Diameters are Actually
Provided by the Manufacturers
2.2 mm diameter, for face.
2.9–3.7 mm diameter, for body contouring, including
breasts.
4.1 mm diameter, for larger areas and big volumes of fat.
3.7 mm diameter probe with a special “cone tip” designed
to emulsify male breasts, but very aggressive also in
fibrous tissue (Fig. 8.4).
FIG. 8.4  Probes.
The efficacy of these probes, which are narrower than
the previous technologies available on the market, is con­
nected to their design, as they are provided with rings (one,
two, or three) at the tip of each probe. These rings have two
special functions:
1. To enhance the efficiency of the emulsification, which
is not limited to the tip, but extends to the last 1.5 cm
of the shaft.
2. To allow a greater selection of options for targeting the
various tissue types (purely fat, mixed, fibrotic), by uti­
lizing different probes.
The number of rings to be chosen depends on the type
of tissue: the most fibrotic is treated with one ring, the less
dense tissue (pure fat ) with three rings.
Technique
The Vaser surgeon may now utilize two further options:
1. The 4.5 mm large probe, for larger volumes, with a higher
percentage of fat emulsification, for 1 minute,depending
on the diameter of the probe.
2. The “cone” tip probe, which is very aggressive in
fibrous tissue, and has been designed for male breast
tissue (gynecomastia) destruction (Fig. 8.4).
Through these incisions the surgeon can reach all the
breast tissues, working in a criss-cross manner. Recently,
the ultrasound device software has been upgraded to pro­
vide the same degree of cavitation with less power, which
reduces the risk of friction injury and burn at the entrance
site; this even allows discontinuing the use of the skin
protector.
Probes
With existing technology, a solid probe is more efficacious
than a hollow probe for cavitation, which is the physical
phenomenon that allows fat fragmentation and destruction.
Moreover, the level of ultrasound energy conveyed by a
hollow probe is limited, and consequently the level of the
cavitations obtained in the tissue is diminished.
The Vaser system (Sound Surgical Technologies,
Denver, CO, USA) provides different sizes and lengths of
solid titanium probes (Box 8.1) expressly designed to fulfill
all purposes in body contouring, as well as being capable
of emulsification through the cavitation effect produced by
the ultrasound energy. The piezoelectric transducer trans­
forms electric energy into “vibration energy”, thus allowing
the solid titanium probe to emulsify the target fat cells.
FIG. 8.3  The three different layers of infiltration (superwet infusion)
of the breast: deep, intermediate, and superficial.

58.e1
Chapter | 8  Ultrasound-assisted breast reduction
These options are not purely an academic difference:
the energy and the wavelength of each probe is selected for
the target tissue, avoiding unnecessary extra power and
wasted energy, which is a potential cause of secondary
unwanted complications (already seen with previous
technologies).
In breast reduction with pure Vaser, I prefer the 2.9 mm
probe, with one ring, for deep layers, and the 3.7 mm, with
three rings, for superficial layers.

59
Chapter | 8  Ultrasound-assisted breast reduction
retraction, the superficial layers are treated initially. Then
the deeper planes are reached, and more time is spent in
thicker areas. Surgeons inexperienced in the procedure
should be especially cautious when performing the tech­
nique, particularly in the subdermal planes.9–12,15–19
Subcutaneous UAL Undermining
Together with UAL application to the fat layers, starting
from the deeper layers and progressing to the more super­
ficial ones, it is advisable to thin the superficial layer of the
subcutaneous tissue of the upper and lower quadrants by
using a different angle pattern, as in standard lipoplasty.20,21
This superficial undermining with low-frequency ultra­
sound energy helps to enhance the retraction of the breast
skin and to redrape the breast skin to the newly shaped and
reduced mammary cone (Fig. 8.6).
OPTIMIZING OUTCOMES
To facilitate these maneuvers, I often place a second tiny
incision at the axilla, and (sometimes) at the areola border.
This helps the superficial work of the probe. The
Larger probes are recommended in all massive volume
cases, including large breasts, and the cone tips in really
fibrotic breasts.
Fat Emulsification
In breast reduction with UAL the duration of the procedure
varies depending on the volume of reduction, the type of
tissue encountered, and the amount of skin retraction
required. A breast with purely fatty tissue is easier to treat
than one with mixed glandular tissue, in which fat cells are
smaller, stronger, and denser (Fig. 8.5).
The author has started utilizing the Vaser ultrasound
device with solid probes (2.9–3.7 mm wide). It delivers
50% of the ultrasound energy in comparison with the older
Sculpture unit (SMEI, Casale Monferrato, Italy), which was
used from 1990 to 2001, while emulsifying fatty tissue
much more efficiently. Treatment of the target tissues starts
with 10–15 minutes of ultrasound energy in fat tissue,
which usually produces between 250 and 300 ml of
emulsion.
The surgical planes, with good criss-cross tunneling and
adequate undermining, are planned in the preoperative
drawings. If large undermining is required for skin
FIG. 8.5  Probe emulsifying deep layers and undermining the super­
ficial layers.
FIG. 8.6  Incisions placed at the inframammary crease, axilla, and
areola margin.
• Upper quadrants, superficial layers, 2–3 minutes
• Lower quadrants, deep layers, 7–20 minutes.

60
PART | 3  Breast reshaping
FIG. 8.7  (A) Preoperative photograph of a 29-year-old woman with
moderate breast hypertrophy. (B) Postoperative view 6 months after
ultrasound-assisted lipoplasty through a submammary of 500 ml of fat
per site.
A
B
undermining has to be complete, with full liberation of all
adhesions within the deeper layers.
Vaser is selective, and does not interfere with the vas­
cular network of the dermal tissue, if properly made. It
divides the connective and supporting structures of the skin.
Rudolph (1991)22 showed the great potential of the dermal
layer in wound contracture. As much as the dermis is
thinned, so much contraction will result, providing the
tissue vascularization is preserved.
Tissues contract more easily, and when combined with
the force of gravity, which helps the upward rotation of the
gland (when decreased in weight), the final result is a
greater contraction of the breast, with a superior antigravity
effect.
POSTOPERATIVE CARE
Suction drainage is routinely applied in the breast for at
least 24–48 h. A custom-made elastic compression support
(silicone-backed adhesive foam pads) is applied for 7–10
days and a bra completes the dressing. These items, together
with skin redraping, help to support the breast in the imme­
diate postoperative period.
CLINICAL RESULTS
Results are visible immediately after surgery; the skin enve­
lope is redraped nicely and the new breast shape and mold
are contoured. The skin and treated breast tissue appear soft
and pliable. The elevation of the nipple–areola complex
resulting from skin contraction and the rotation of the breast
mold is immediately visible.
The major postoperative nipple–areola complex eleva­
tion was 5 cm.
Emulsification of fatty breast tissue ranged from a
minimum of 300 ml per breast in mild reductions and breast
lifts to a maximum of 1200 ml of aspirate for each breast
in large breasts.
Elevation of the nipple–areola complex up to 5 cm was
obtained in large volume reductions in combination with
thinning of the subcutaneous layer.
There was no evidence of suspicious calcification result­
ing from surgery at the 5-year postoperative follow up.
Essentially, an increase in breast tissue fibrosis was notice­
able in the postoperative mammograms, which was respon­
sible for the new consistency, texture and tone of the breasts,
and also responsible for the lifting of the breasts (Figs
8.7–8.9).
Mastopexy
I have applied the technique in clinical cases with the
patient expressively refused visible breast cutaneous scars,
and the potential correction of ptosis with an anatomical
implant. The upward rotation of the breast and the retrac­
tion can finally elevate the breast by 2–4 cm from its initial
position (Figs 8.9 and 8.10). A supporting bra has to be
applied for the first 4 weeks after surgery; despite this, I
strongly believe that a similar bra should be advised forever
in patients with large breasts or a tendency to ptosis
(Fig. 8.11).
Histologic Changes
The breast tissue that underwent emulsification with UAL
was analyzed histologically by Chun, Taylor and Van
Meter (2002)23 who presented a paper at the American
Society for Aesthetic Plastic Surgery (ASAPS) meeting
in Las Vegas. They operated on 10 patients with large
breasts using the Genesis Contour device (Mentor HS,
Santa Barbara, CA, US), with breast UAL. Then, with
open surgery, a breast specimen was removed, weighing
430–1530 g.

60.e1
Chapter | 8  Ultrasound-assisted breast reduction
Vaser can also be applied in clinical breast surgery cases
that present minor degrees of glandular ptosis. As we know,
by decreasing the volume of the breast, it is normal to have
an upward rotation of the gland itself. Also, the areola tends
to shrink when the underlying tissue is diminished in size
and volume.

61
Chapter | 8  Ultrasound-assisted breast reduction
In 2006, at the ASAPS meeting in Orlando (FL, USA),
Nagy and McCraw (Mississipi University Medical School,
St Louis, Missouri, US) first presented the combination of
breast fat emulsification by Vaser with open surgery breast
reduction. They re-introduced the technique of Raymond
Passot, a French surgeon, who in 1925 published the
so-called “BUTTON” mammoplasty or the “ no vertical
scar” reduction, which became the most common method
of breast shaping in Europe before World War II (Fig. 8.12).
Markings
I start marking the new nipple position, which is from
19–21 cm from the midclavicular point (as in all classic
measurements – this is the Pitanguy referral point). Then I
mark the inframammary fold, which ranges from 15–23 cm
(Fig. 8.13). The flap margin is 8–9 cm below the new
nipple site.
The existing inframammary fold is marked. Medial and
lateral points are marked. The upper quadrants of the breast
No gross pathological changes were noted at the time
of surgery, and microscopic diagnosis included fibrocystic
changes and stromal fibrosis.
No atypia and no malignancies were found. The long-
term follow up shows clearly that the emulsified fat, when
not aspirated, will dissolve in a few days or weeks.
An area of relative fibrosis may appear at 1 or 2 months,
interval; palpable nodes or lumps were a rare event in the
large series of patients operated on (from 2002 to 2006, 200
breast reductions and/or pexies were performed, alone or in
combination with other body contouring procedures).
FIG. 8.8  (A) Preoperative view of breast hypertrophy and planning; red
dotted area indicated fibrotic breast tissue not to be addressed. (B) 1 year
postop breast nipple raised from 21 to 18 cm from intrasternal notch.
A
B
FIG. 8.9  Patient 26 years old, 550 ml aspirate perside, UAL 21
minutes. (A) Preoperative view. (B) postoperative view.
A
B

62
PART | 3  Breast reshaping
FIG. 8.10  Patient 24 years old, 450 ml of aspirate per side, UAL 22 minutes. (A, C) preoperative views. (B, D) postoperative views.
A
B
C
D
are infiltrated with tumescent solution, then Vaser is applied
to emulsify the fat in this area. In this case, no skin protector
is applied, as the skin in this area is due to be de-epithelialized
for breast reduction.
After completing aspiration of emulsified fat, the lower
flap is detached from the chest wall, with a central large
inferior pedicle based on perforators from the pectoralis
muscle. The upper quadrants, already treated with Vaser
(Fig. 8.14), show the network of the subcutaneous breast
tissue, as it appears after emulsification of fat and aspira­
tion. All the supporting structures of the skin (elastic
bundles, vessels, nerves, connective supports) are con­
served. This pattern is similar to what happens in closed
breast reduction. As the flap is reduced, it is advanced to
fill the empty space. The new nipple is positioned and cen­
tered on its pedicle.

63
Chapter | 8  Ultrasound-assisted breast reduction
FIG. 8.11  Patient 32 years old, 550 ml of aspirate per side, UAL 25
minutes. (A,B) postoperative views.
A
B
FIG. 8.12  The Passot method.
FIG. 8.13  (A) Best range of visual is 15–23 cm; (B) Indicating the IM
fold.
A
B
The Passot technique combined with Vaser has
been applied to several types of breast ptosis. I have per­
formed large reductions with this technique (up to 2900 g
per side) (Fig. 8.15), or operated on the so-called “long
breast”.
The typical case where I actually combine the Passot
technique with Vaser is a moderate degree of ptosis, 26–
28 cm from the midclavicular point, with a mild to moder­
ate hypertrophy (Fig. 8.16). Results are satisfactory and
tend to improve with time (Box 8.2).

64
PART | 3  Breast reshaping
FIG. 8.14  Vaser effect after 500 ml aspiration.
Lipoplasty Society of North America (LSNA), and the Aes­
thetic Society Education and Research Foundation
(ASERF), the learning curve for UAL is longer than that
for standard lipoplasty.
Specifically, practitioners must learn how to work close
to the subdermal layer with a solid titanium probe to defat
this layer and obtain good skin retraction while avoiding
FIG. 8.15  Large reduction, 2900 g per side.
A
B
BOX 8.2  The Secrets of the Success of the Passot
Technique Combined with Breast Reduction
1. Shaping, under control, the upper and lower quadrants
of the breast
2. Maintaining the vascularization of the upper quadrants
by using Vaser, as this is a selective technique of
emulsification
3. Repositioning of the nipple–areola complex without
tension, which ensures a good scar (no distortion, no
widening)
4. Surgeons must possibly reconsider the priority in scar
selection for breast reduction. For most women, the
inframammary scar is preferable to the vertical scar, as
it is less visible, despite being longer
COMPLICATIONS AND
THEIR MANAGEMENT
No major complications occurred in the author’s series of
patients. It should be emphasized that such good results
require extensive experience with UAL.
As stated by a task force on UAL established by ASAPS,
the Plastic Surgery Educational Foundation (PSEF), the

65
Chapter | 8  Ultrasound-assisted breast reduction
FIG. 8.16  A (A) Preoperative view. (B) Five months postop, 600 g per
side.
A
B
complications such as skin burns and skin necrosis. To
safely work close to the skin, two conditions are mandatory.
The surgeon must be experienced in ultrasound-assisted
body contouring and the correct ultrasound device (to maxi­
mize the cavitation effects while minimizing the thermal
effects) must be selected.
Skin Necrosis
Fat necrosis with secondary tissue induration is a typical
sequela of ultrasound surgery. When it is localized in small
areas, such necrosis can be treated with massage or local
infiltration of corticosteroids to soften the area.
Loss of Sensation
Loss of sensation is generally limited to the first 3 weeks
after surgery. Recovery is rapid because the central cone of
the breast is composed mainly of pure parenchyma and is
not touched during surgery. Skin sensation is recovered in
a few weeks.
Hematoma
Hematoma formation is another potential complication,
though no cases occurred in this series. A photograph of a
case of hematoma in a patient treated by another surgeon
is shown in Fig. 8.17. This hematoma was localized in the
subaxillary region, where the tumescent infiltration was
initially administered. The surgeon who performed the
operation revealed that the anesthesiologist incorrectly used
standard sharp needles rather than blunt infiltration can­
nulas. The formation of the hematoma, which appeared
immediately after the infiltration, was thus related to an
incorrect tumescent infiltration technique and not to the
breast reduction with UAL.
Mastitis
Mastitis, an inflammatory response of the breast paren­
chyma to surgery, occurred in a few patients early in the
series. Once surgery was avoided for patients at or near their
menstrual period, only a minor inflammatory response was
noted. When encountered, mastitis rapidly subsided with
immediate treatment consisting of oral anti-inflammatory
drugs and wide-spectrum antibiotics for 3 days.
Seroma
Seroma formation is a potential complication of any breast
surgery. Regular application of suction drainage and breast
compression for several days with a foam pad and a bra
prevent this event.
Selectivity and Specificity of Ultrasound
Large amounts of fat are often found in patients with breast
hypertrophy, even among thin adolescents. Lejour and
Abboud14 emphasized that once the fat is removed by lipo­
plasty before breast reduction, the proportion of glandular
tissue, connective tissue vessels, and nerves is increased.

65.e1
Chapter | 8  Ultrasound-assisted breast reduction
These structures are important for maintaining vascular­
ity, sensitivity, and lactation potential. Lejour13 affirmed
that if the breasts contain substantial fat, weight loss may
result in breast ptosis. The degree of recurrent ptosis can be
minimized if lipoplasty is performed preoperatively to
reduce the fatty component of the breasts. This observation
anticipated the great potential of UAL for breast surgery.
The clear limits of standard lipoplasty, with mechanical
indiscriminate destruction of fat and surrounding elements
followed by power aspiration of the destroyed tissue, are
particularly enhanced in breast surgery, where specialized
structures have to be carefully preserved.
Because it is a selective technique, UAL may be applied
in breast surgery to destroy and emulsify only the fatty
component of the breast tissue without affecting the breast
parenchyma for which the ultrasound energy has no speci­
ficity. The specificity of the technique is connected with the
cavitation phenomenon and the efficiency of the system
hinges on the type of the titanium probe used and the energy
level selected. Lejour13 argued that the suctioning of breast
fat also made the breast suppler and more pliable, which
facilitates shaping, especially when the areola pedicle is
long. This consideration is particularly important with fatty
breasts, which have a less reliable blood supply. These
benefits are significantly increased by the use of UAL
because the specificity of this technique spares the vessel
network.
The selectivity of UAL was demonstrated by Fisher,24,25
and Palmieri26 in their studies on the action of the ultrasound
probe in rat mesenteric vessels. Later, Scheflan and Tazi25
introduced endoscopic evaluation of UAL. They used a
By contrast, UAL spared vessels, nerves, and elastic
supporting fibers. Alterations in breast tissue resulting from
the use of UAL were a thickened dermal undersurface,
markedly thickened vertical collagenous fibers, intact lym­
phatic vessels, and intact blood vessels. The horizontal and
vertical thickening and shortening of the collagen in the
dermis and ligamentous fibers are responsible for the
remarkable skin tightening that follows subcutaneous stim­
ulation with the ultrasound probe. This is of great value in
breast surgery, where volume reduction has to be accom­
plished by skin redraping and recontouring of the breast
shape.
As noted by Lejour,13 retraction of the skin after stan­
dard lipoplasty cannot be expected to be sufficient to
produce a satisfactory breast shape. Subcutaneous aspira­
tion must be extensive to obtain the necessary skin retrac­
tion, and the risk of localized skin necrosis resulting from
excessive superficial liposuction cannot be ignored.28
Stortz endoscopic system and camera (Stortz, Tuttlingen,
Germany) to videotape the action of the titanium probe
within the ultrasound device in the superficial layers, veri­
fied by needle depth, after standard infiltration with the
tumescent technique. UAL was performed with criss-cross
tunnels, and the procedure was recorded on videotape. An
adjacent area was treated with standard lipoplasty. The tech­
nique was compared with standard lipoplasty, which was
also endoscopically assisted and monitored. The authors
found that standard lipoplasty appears to be the more aggres­
sive technique, with the mechanical destruction of the entire
subcutaneous tissue, despite the use of 2–3 mm wide blunt
cannulas.

66
PART | 3  Breast reshaping
FIG. 8.17  (A) Skin necrosis of the breast medial flap. The surgeon
performed a standard breast reduction and then attempted to debulk the
medial flap without infiltration of tumescent solution. Skin necrosis
resulted, with spontaneous healing after 3 weeks. (Patient referred by
another surgeon.) (B) Breast hematoma caused by infiltration of Klein
solution with incorrect instrumentation. The anesthesiologist used a sharp
needle rather than the classic atraumatic blunt needle. The hematoma
required evacuation, after which regular healing followed. (Case referred
by another surgeon.)
A
B
Calcifications
Lejour13 and Lejour and Abboud14 argued that the risk of
postoperative fat necrosis or calcifications was the reason
many surgeons avoided the use of lipoplasty in the breast.
The main cause of fat necrosis is breast ischemia brought
about by extensive dissection or direct mechanical damage,
with resultant venous drainage. Calcification in breast
reduction surgery may derive from an area of fat necrosis
or breast necrosis and subsequent scarring. Such calcifica­
tions are most often located at the incision lines (periareo­
lar, or vertical scar in the inverted-T approach), where more
tension is placed in approximating the lateral and medial
flaps. However, when the tension is too high, areas of
necrosis could arise from the approximating suture and later
cause calcifications that are visible on mammography.
However, the risk of such complications in UAL procedures
is quite low.
Potential Risks
In November 1998, a conference on UAL safety and effects
was held in St Louis, MO, USA, sponsored by the ASERF
and the PSEF.31 The panel was organized in response to an
article by Topaz32 that raised questions about the safety of
UAL. Topaz speculated that thermal effects and the free
radicals generated during UAL might result in neoplastic
transformation and other long-term complications, as a
consequence of the physical effect known as sonolumines­
cence. Those attending the conference represented multiple
scientific disciplines, including plastic surgery, physics,
lipid chemistry, cancer biology, and mechanical biophysics.
The participants agreed that scientists did not yet under­
stand the mechanism of UAL action, though multiple mech­
anisms were probably involved, such as mechanical forces,
cavitations and thermal effects.
CONCLUSION
The use of UAL for reduction of fatty breasts and masto­
pexy is effective and safe when applied in selected patients
and performed by a surgeon with expertise in ultrasound-
assisted body contouring. The selectivity of UAL enables
emulsification of the fatty component of the breast paren­
chyma while sparing the glandular tissue and vascular
network. Furthermore, long-term mammographic studies
have revealed no alteration of morphology of the breast
parenchyma resulting from this technique. The typical
mammographic appearance of breast tissue after UAL is a
denser breast.35,36
REFERENCES
1. Zocchi M. Clinical aspects of ultrasonic liposculpture. Perspect Plast
Surg 1993;7:153–74.
2. Zocchi M. The ultrasonic assisted lipectomy (UAL): physio­
logical principles and clinical application. Lipoplasty 1994;11:
14–20.
3. Zocchi M. Ultrasonic assisted lipectomy. Advances in Plastic and
Reconstructive Surgery. Vol. 11. St Louis, MO: Mosby Year Book;
1995.

66.e1
Chapter | 8  Ultrasound-assisted breast reduction
From a mammographic viewpoint, the typical appear­
ance of a breast reduction with UAL demonstrates predict­
ably less scarring and fewer calcifications than occur in the
standard open technique. Courtiss34 reported similar mam­
mographic evidence in a denser breast after breast reduction
by lipoplasty alone. No malignancies were reported.
The question of whether potential lactation is affected
by UAL remains unanswered. The technique was used for
breast reduction and mastopexy in younger and older
patients. In the younger group, 16 patients breast-fed their
babies regularly. The other 14 patients were lost to follow
up. However, none of these patients, or their gynecologists,
reported any problems to the surgeon or to the hospital, and
no complications have been reported by other surgeons
around the world who use this technique.
Mammography showed a significant increase in breast
parenchymal fibrosis. The calcifications that appeared were
benign and were typically small, round, less numerous, and
more regular than those characteristic of malignancy. Com­
parison of the mammographic results showed that micro­
calcifications are less likely to develop with UAL. It is
likely that scar tissue caused by breast reduction with elec­
trocautery or by necrosis resulting from the tension of inter­
nal sutures may more frequently cause calcifications or
irregular mammographic aspects of the operated paren­
chyma. Particularly in standard breast-reduction surgery,
they can appear at the areola line and at the site of the verti­
cal scar.
With reference to the application of UAL to breast
surgery, we investigated the histology of the breast fat
tissue before and after UAL breast surgery (with serial
biopsies at 6 months and 1 year after surgery) and the mam­
mographic appearance of the breast before and 1, 2 and 3
years after surgery, particularly with respect to calcification.
The results were evaluated by a sonologist not directly
involved with the clinical research.33 Histologic studies
revealed an increased fibrotic response to thermal insult,
with a prevalence of fatty scar tissue, in all specimens
evaluated.
Additional research has revealed that long-term compli­
cations or negative bioeffects (including DNA damage and
oxidation free radical attack) are probably not serious safety
concerns for UAL.
Calcifications in breast parenchyma are to be expected
after any mammoplasty procedure. In reduction mammo­
plasty, it is preferable that they be localized along the breast
scars.29 When lipoplasty is performed in addition to the
mammoplasty procedure, benign macro-calcifications are
slightly more numerous in the parenchyma than they are in
breasts reduced without lipoplasty. This may occur because
of the trauma caused by lipoplasty or because lipoplasty
suction is applied to the most fatty breasts, which are more
prone to liponecrosis.30 However, 1 year after fatty breast
reduction with UAL, follow up mammography revealed
only a slight increase of small microcalcifications, similar
to those found after other mammary procedures.

67
Chapter | 8  Ultrasound-assisted breast reduction
21. Teimourian B, Massac E Jr, Wiegering CE. Reduction suction mam­
moplasty and suction lipectomy as an adjunct to breast surgery.
Aesth Plast Surg 1985;9:97–100.
22. Rudolph, et al. Reconstructive Plastic Surgery, Volume 1, Converse
J. M., Saunders; 1991;69–77.
23. Chun, Taylor & Van Meter 2002, ASAPS (American society Aes­
thetic Plastic Surgery) annual meeting in Las Vegas, communication
(Abstract of meeting).
24. Gibson T, Kenedi RM. Factors affecting the mechanical character­
istics of human skin. In: Proceedings of the Centennial Symposium
on Repair and Regeneration. New York: McGraw-Hill Book
Company; 1968. p. 87.
25. Gibson T, Stark H, Kenedi RM. The significance of Langer’s lines.
In: Hueston JT, editor. Transactions of the Fifth International Con­
gress of Plastic And Reconstructive Surgery. Australia: Butterworths;
1971. p. 1213.
26. Palmieri B. Studio sull’ azione degli ultrasuoni sul tessuto vasculare
del ratio. Riv Ital Chir Plast 1994;9:635–9.
27. Schleflan M, Tazi H. Ultrasonically assisted body contouring. Aesth
Plast Surg 1991;16:117–22.
28. Becker H. Liposuction of the breast. Presented at the Lipoplasty
Society of North America meeting, September 1992.
29. Mitnick JS, Roses DF, Harris MN, Colen SR. Calcifications of the
breast after reduction mammoplasty. Surg Gynecol Obstet 1990;
171:409–12.
30. Lejour M, Abboud M. Reduction of mammaplasty scars: from a
short inframammary scar to a vertical scar. Ann Chir Plast Esthet
1990;35(5):369–79.
31. Young VL, Schorr MV. Report from the conference on ultrasound
assisted liposuction safety and effects. Clin Plast Surg 1999;26:
481–524.
32. Topaz M. Possible long-term complications in UAL induced by
sonolution minescence, sonochemistry, and thermal effects. Aesth
Surg J 1998;18:19–24.
33. Di Giuseppe A, Santoli M. Ultrasonically assisted breast reduction
and mastopexy. Int J Cosm Surg Aesth Dermatol 2001;3(1):23–9.
34. Courtiss EH. Breast reduction by suction alone. In: Spear S, editor.
Surgery of the Breast: Principles and Art. Philadelphia: Lippincott-
Raven; 1998.
35. Di Giuseppe A. Vaser-assisted breast reduction. In: Shiffman M,
editor. Mastopexy and Breast Reduction. Principles and Practice.
New York: Springer; 2009.
36. Di Giuseppe A. Mastopexy (breast lift) with ultrasound assisted
liposuction. In: Shiffman M, Di Giuseppe A, editors. Liposuction
Principles and Practice. New York: Springer; 2006.
4. Zocchi M. The ultrasonic assisted lipectomy, instructional course.
San Francisco: ASAPS Annual Meeting; March 1995.
5. Zocchi M. The treatment of axillary hyperadenosis and hyperhidrosis
using ultrasonically assisted lipoplasty. Presented at the Meeting of
the International Society of Ultrasonic Surgery, Faro, Portugal,
November 1995.
6. Zocchi M. Basic physics for ultrasound assisted lipoplasty. Clin Plast
Surg 1999;26:209–20.
7. Sampaio Goes JC. Periareolar mammoplasty: double skin technique
with application of polyglactine or mixed mesh. Plast Reconstr Surg
1996;97(5):959–68.
8. Benelli L. A new periareolar mammaplasty: round block technique.
Aesth Plast Surg 1990;14:93–100.
9. Di Giuseppe A. Mammoplasty reduction and mastopexy utilizing
ultrasound liposuction. Mammographic study preoperative. Venice,
Italy: 46° National Congress of Italian Society of Plastic Reconstruc­
tive and Aesthetic Surgery; June 1997.
10. Di Giuseppe A. Ultrasonically assisted liposculpturing. Am J Cosm
Surg 1997;14(3):317–27.
11. Di Giuseppe A. Reducion mamaria y pexia con la asistencia de la
lipoplastia ultrasonida. Lipoplastia 1998;1(1):16–26.
12. Di Giuseppe A. UAL for face-lift and breast reduction. Abstract for
World Congress on Liposuction Surgery. California: Pasadena;
October 1998.
13. Lejour M. Reduction of large breasts by a combination of liposuction
and vertical mammoplasty. In: Cohen M, editor. Master of
Surgery: Plastic and Reconstructive Surgery. Boston: Little, Brown,
1994.
14. Lejour M, Abboud M. Vertical mammoplasty without inframammary
scar and with liposuction. Perspect Plast Surg 1990;4:67.
15. Di Giuseppe A. Abstract at the 3rd European Congress of Cosmetic
Surgery. Themes: Ultrasound Assistance for Body Contouring,
Breast Reduction and Face Lift. How to do it? Berlin: April 1999.
p. 23–5.
16. Di Giuseppe A. Abstract at the XV Congress of the International
Society of Aesthetic Plastic Surgery (ISAPS). Themes: Harmonic
Lift or Ultrasonically Assisted Skin Remodelling of Face (Video).
Tokyo: Ultrasonic Assisted Lipoplasty of the Breast (Poster); April
2000.
17. Di Giuseppe A. Ultrasonically assisted breast reduction and masto­
pexy. Int J Cosm Surg Aesth Dermatol 2001;3(1):23–9.
18
Di Giuseppe A. Ultrasound assisted breast reduction and mastopexy.
Aesth Surg J 2001;21(6):493–506.
19. Di Giuseppe A. Breast reduction with ultrasound assisted lipoplasty.
Plast Reconstr Surg 2003;112(1).
20. Teimourian B. Suction Lipectomy and Body Sculpturing. St. Louis,
MO: CV Mosby; 1987.

68
© 2013 Elsevier Inc
Chapter 9 
Key Points
●
This is the most common combination in body
contouring surgery.
●
The population is comprised of females between their
30s and 50s.
●
Several technical improvements have been described
in the last 50 years.
●
Liposuction techniques have laid the foundation for
lipoabdominoplasty.
●
There is a good safety profile for the combination of
these procedures
Combined abdominal contouring
and mastopexy
Carlos O. Uebel
INTRODUCTION
The combination of abdominoplasty and mastoplasty is
very common, especially for patients post pregnancy or
post weight loss with abdominal laxness, striae, muscle
rectus diastases, and breast ptosis. It is most commonly
performed in women in the age range 30–50. Many tradi­
tional abdominoplasty and mammaplasty techniques have
been published in the last 50 years with extraordinary
results, but with the introduction of liposuction, described
by Illouz1 in 1980, we had a new tool for body contouring
surgery. This opened up a new treatment method for lipo­
dystrophies in the epigastric, flank, dorsum, trochanteric,
and buttock areas. The procedure combining abdomino­
plasty and liposuction was called “lipoabdominoplasty,”
and since then many new techniques and modifications
have been proposed.
Since abdominoplasty was first described by Callia2 and
Pitanguy,3 many refinements have been published in the
literature.4–14 In 1975, Sinder15 described the superior epi­
gastric incision approach to estimate a safe inferior abdomi­
nal flap excision. Planas16 published a similar procedure
in 1978 and Serson Neto17 and Pontes18 described the geo­
metrical inferior flap block resection. Mammaplasty, when
combined with abdominoplasty, can take the form of breast
augmentation, mastopexy, or breast reduction. For breast
augmentation we prefer to use silicone texturized prosthe­
ses. For breast reduction we prefer the Silveira Neto der­
moglandular rotation flap, published in 197619 and
subsequently improved by Uebel in 1978.20 For mastopexy
we use the Pitanguy21 or Ariê22 techniques with a superior
pedicle flap. There are many other techniques in the litera­
ture but these are the most used by us in body contouring
surgery – very simple procedures that maintain physiologi­
cal function and good esthetic results. Stemming from those
techniques, we have introduced some important approaches
and details to ensure consistency. This will be discussed
further in this chapter.
ABDOMINOPLASTY
In this chapter we will address abdominoplasty combined
with mammaplasty for patients with abdominal laxness,
rectus muscle diastases, localized lipodystrophy with breast
ptosis, hypomastia, or breast hypertrophy. These are very
common pathologies after pregnancy and are also seen in
post-bariatric surgical patients.
Preoperative Preparation
In a standing position we take pictures with a digital camera
(10 megapixels) and we mark the incisions of the abdomen
wall and breasts, as well as all the areas to be treated with
liposuction. We estimate the amount of skin and breast
tissue to be removed, and in the sitting position we estimate
the amount of skin and fat to be removed from the abdomi­
nal wall (Fig. 9.1A–E).
With the patient in a sitting position, we estimate the
amount of skin resection needed.23 We identify the lateral
inguinal folds (Fig. 9.2A, B) and a low abdominal curved
line is delineated approximately 8 cm from the labia major
vertex.
FIG 9.2B APPEARS ONLINE ONLY
Part 3  Breast reshaping

68.e1
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.2  With the patient in a sitting position, we identify the ingui­
nal groove extremities and the inferior suprapubic incision is
outlined.
B

69
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.1  (A–E) Typical 42-year-old patient, pregnancy of 3 children, with abdominal laxness, striae, rectus muscles diastasis, and breast
ptosis.
A
B
C
D

70
PART | 3  Breast reshaping
E
FIG. 9.1  Continued
FIG. 9.2  With the patient in a sitting position, we identify the ingui­
nal groove extremities and the inferior suprapubic incision is
outlined.
A
Surgical Technique
Tumescent Infiltration and
Assisted Liposuction
All areas to be lipoaspirated and undermined are infiltrated
with a saline solution containing epinephrine at 1 : 500 000
concentration to avoid excessive bleeding (Fig. 9.5A, B).
FIG 9.5 APPEARS ONLINE ONLY
The patient is positioned prone and the flank and tro­
chanteric areas are manually lipoaspirated with a 3 mm
cannula. The patient is then rotated to the supine position
and extensive liposuction is performed on the entire
abdomen and epigastric areas. It is important to reach the
inframammary region and the xiphoid appendix, extending
to the chondrocostal border to fully loosen this area, as
described by Avelar25 and Saldanha.26 For this maneuver we
use an angular cannula, described by Reggazzo (personal
communication), to prevent internal perforations. The only
region to be avoided is the lateral superior flank, in order
to avoid damaging the neurovascular bundles that give arte­
rial, venous, and neural support to the flap (Fig. 9.6A, B)
(Fig. 9.7A, B, C).
FIG 9.6, 9.7C APPEARS ONLINE ONLY
Supraumbilical Incision and Epigastric
Tunnel Undermining
A supraumbilical incision is first done and an epigastric
tunnel is undermined to the xiphoid appendix. It is
With the patient in a standing position, a line drawn
from the superior umbilical region is connected to both
extremities and the areas to undergo liposuction are out­
lined (Fig. 9.3).
Anesthesia
High epidural anesthesia via catheter is almost always used,
with insertion in the thoracic 11–12 spinal level and con­
nected to a continuous infusion pump. A 15 ml solution of
7.5 mg/ml ropivacaine HCl (Naropin) and 30 mg sufentanil
citrate is infused into the epidural space and an analgesic
solution is prepared for postoperative administration via the
infusion pump (100 mg sufentanil citrate and saline solu­
tion 0.9%, 100 ml at a speed of 5 ml per hour.24 Elastic
bandages are applied to the legs to prevent thrombovenous
embolism (Fig. 9.4A–D).
FIG 9.4A–D APPEARS ONLINE ONLY
Area loosened by cannula
Tunnel undermining
Area to be preserved
End inguinal fold
Iliac crest
± 7cm from the labia
major vertex
FIG. 9.3  With the patient in a standing position, we outline the
supraumbilical incision connecting both extremities and we outline
the areas to be loosened and undermined. A periareolar incision is
outlined for breast prostheses inclusion

70.e1
Chapter | 9  Combined abdominal contouring and mastopexy
FIG. 9.4  (A–D) Epidural anesthesia in the 11–12 thoracic spinal space with catheter for continuous analgesic infusion and leg bandages to
prevent thrombovenous embolism.
A
B
C
D

70.e2
PART | 3  Breast reshaping
FIG. 9.5  All areas to be treated are infiltrated with a saline solution
with epinephrine 1 : 500 000.
A
B
FIG. 9.6  Dorsum and trochanteric areas treated.
A
B
FIG. 9.7  Suprachondrocostal area loosened by angular cannula.
Flank lateral area is preserved.
C