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A. L. Weinstein and F. Nahai
58. Swanson E.Why risk assessment models are ineffective in predicting venous thromboembolism in plastic surgery patients. Aesthet
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60. Hatef DA, Kenkel JM, Nguyen MQ, Farkas JP, Abtahi F, Rohrich
RJ, Brown SA.Thromboembolic risk assessment and the efcacy
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61. Vasilakis V, Klein GM, Trostler M, Mukit M, Marquez JE, Dagum
AB, Pannucci CJ, Khan SU.Postoperative venous thromboembolism prophylaxis utilizing enoxaparin does not increase bleeding
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62. Sarhaddi D, Xu K, Wisbeck A, Deigni O, Kaswan S, Prada C, Lund
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Gluteal Fat Transfer: AScientific
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Validation
DenizSarhaddi, CaitlinFrancoisse, andFoadNahai
Contents
2.1 Introduction 11
2.2 History and Controversy 11
2.3 Fat Embolism Versus Fat Embolism Syndrome 12
2.4 ASERF Task Force Recommendations and Response 12
2.5 Enhanced Safety Efforts 13
2.6 BBL Today 13
References 14
2
2.1 Introduction
Gluteal augmentation via autologous fat grafting, colloquially termed the “Brazilian Butt Lift” (BBL), represents one
of the fastest growing areas of plastic surgery in the United
States. The American Society of Plastic Surgery estimates
over 28,000 procedures were performed in 2019, nearly double the number performed just 5 years prior [1, 2]. This
growth has continued despite its nefarious reputation as one
of the deadliest surgical cosmetic procedures. Early estimates from the Aesthetic Surgery Education Research
Foundation (ASERF) described the mortality rate as between
1in 2250 to 1in 6214, at least triple that of then next riskiest
procedure, abdominoplasty [3, 4]. This reputation, however,
may be misleading. New safety recommendations have
changed the safety prole of this once infamous procedure,
dropping the mortality by over 75% [5]. Evidence continues
to emerge suggesting that with proper precautions, gluteal
fat augmentation provides a safe and effective strategy to
body contouring.
D. Sarhaddi
Saint Louis Cosmetic Surgery, Inc., Chestereld, USA
C. Francoisse
Saint Louis University Hospital, Saint Louis, USA
e-mail: caitlin.francoisse@health.slu.edu
F. Nahai (*)
Emory University, Atlanta, USA
2.2 History andControversy
The quest for gluteal rejuvenation traces back over 50years,
with Pitanguy’s reports of improved gluteal aesthetics
through resection of the trochanteric regions and the gluteal
fold [6]. However, it was not until the 1980s that surgeons
turned to the relatively new technology of liposuction to
restore volume and improve contour. In 1986, Gonzalez
etal. published the rst report of autologous gluteal fat grafting [7]. Even in these early reports, authors emphasized the
importance of avoiding large depots and injecting fat at different levels, themes that would return later as safety concerns would later arise. This body of work continued to grow
with Toledo in 1980s, followed by others including CardenasCamerena, Roberts, and Mendieta in the decades to follow
which demonstrated efcacy of gluteal augmentation with
this technique [8–11].
However, early pioneers of this technique noted that
resorption of fat grafts can impact long-term results, prompting interest on how to maximize graft longevity. One early
study by Guerroerosantos etal. investigated long-term survival of fat grafts placed into different planes in rat models
[12]. Experimental results demonstrated improved survival
with muscular injection instead of subcutaneous deposition.
Although this study was experimental in nature, it quickly
translated to clinical applications, namely small volume fat
grafting for facial contouring [13–15]. Recognizing its suc-
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_2
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D. Sarhaddi et al.
cess in this context, some surgeons began to scale up this
application to large volume, muscular injection for gluteal
augmentation. Unfortunately, this technique would have two
major implications for patient morbidity and mortality.
As the popularity of this procedure rose, so did concerns
over its reported safety. In 2015, Cárdenas-Camarena
detailed 22 deaths in Mexico and Colombia due to pulmonary fat embolism after gluteal fat during a 15-year period,
sending shockwaves through the aesthetic surgery community [16]. Prior to this, there was only an isolated case
report of fat embolism mortality in Los Angeles, published
in the year prior [17]. Cardenas-Camarena reported that
macroscopic fat emboli caused medium and large vessel
obstruction, causing immediate cardiovascular collapse at
the time of surgery. The volumes of fat injected were relatively small, just over 200 cc on average, but the impact
was profound. Autopsy results showed fat in the deep muscle tissue surrounding the vessels and the rupture of gluteal
veins, implicating deep plane placement of fat as a key factor in mortality [16].
2.3 Fat Embolism Versus Fat Embolism
Syndrome
Fat embolism syndrome (FES) was a known complication of
liposuction, prior to Cárdenas Camerena’s work [18]. FES
results from small lipid globules entering the vascular system and obstructing blood vessels leading to a systemic
inammatory response and ultimately tissue and organ damage. It usually manifests 12–72h postoperatively with respiratory distress, altered mental status, and petechial rash [19,
20]. The results can be deadly with an up to 20% reported
mortality rate [21].
However, Cardenas-Camarena’s landmark study suggested an entirely different mechanism was at play. Fat
embolism is distinct from fat embolism syndrome (FES). Fat
enters the blood stream through the gluteal veins. These are
either cannulated directly or transected traumatically with
the grafting cannula. If the vein is transected, the fat enters
the blood stream via a pressure gradient. Lipoinjection creates an area of higher pressure relative to the venous system,
facilitating movement of the fat into the transected vein [22].
Fat can enter the blood stream in either macroscopic form,
causing cardiopulmonary obstruction, or microscopic form,
leading to reactive airway compromise, hemorrhage, and
edema [19].
Whereas fat embolism syndrome appears up to 3 days
postoperatively, macroscopic fat emboli can occur intraoperatively. This was demonstrated by Bayter-Mari etal. who
reviewed the medical records and autopsy reports of 16
patients who died during gluteal augmentation with fat grafting [23]. They found 75% of patients developed issues intraoperatively with the remaining patients developing symptoms
in the recovery unit. On average, patients died within 7h of
the start of surgery. All patients had microemboli in their
lungs; the majority (62.5%) also had macroscopic emboli in
their lungs, pulmonary vessels, and cardiac vessels.
2.4 ASERF Task Force Recommendations
andResponse
Recognizing safety concerns surrounding the procedure, the
Aesthetic Surgery Education Research Foundation (ASERF)
assembled a dedicated Gluteal Fat Grafting Task Force in
2015 to prole this procedure’s risk prole. Their results
were astonishing: they estimated the mortality rate between
1in 2250 to 1in 6214, a risk 10–20 times greater than the
average for aesthetic surgery procedures performed in facilities accredited by the American Association for Accreditation
of Ambulatory Surgery Facilities (AAAASF) [3]. The task
force outlined the common autopsy ndings of deceased
BBL patients which included fat in and beneath the gluteal
muscles, damage to the superior and inferior gluteal veins,
and massive fat emboli in the heart and/or lungs [24]. To help
mitigate risk, ASERF also established recommendations
which included using a large (>4mm), single hole cannula,
injecting only into the subcutaneous plane only while the
cannula is in motion, and vigilantly avoiding a downward
cannula angle [3].
In a 2018 statement, the task force announced a multisociety launch of focused research efforts into gluteal fat
grafting safety. However, due to the continued death toll
from the BBL, a second “Urgent Warning to Surgeons” was
sent just 5months after the rst [25]. This time, with writing
in all capital letters, ASERF called for improved safety,
avoidance of intramuscular injection, surgeon vigilance, and
possible reconsideration of whether the procedure should
still be offered.
This work sent ripples through the aesthetic surgery community. Leaders across the international aesthetic surgery
community questioned whether the procedure posed an
acceptable risk to patients [26]. In October 2018, at the
British Association of Aesthetic Plastic Surgery (BAAPS)
Annual Meeting, all members were advised to stop performing BBL procedures until more data were collected [27]. The
British Association of Plastic Reconstructive and Aesthetic
Surgeons (BAPRAS) was “fully supportive of the BAAPS
decision.” [28] In June 2019, the state of Florida went so far
as to pass an emergency rule prohibiting surgeons from
injecting fat into or below a patient’s gluteal muscles [29].
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2.5 Enhanced Safety Eorts
Spurred by the Aesthetic Surgery Education Research
Foundation (ASERF) recommendations, there has been a
boom in literature regarding anatomy, safety, and BBL practice, which has given surgeons more in-depth information to
guide techniques when performing this procedure.
Numerous anatomical studies have elucidated ways to fat
graft safely in the gluteal region. It has been clearly demonstrated that there is no “safe zone” in the intramuscular or
submuscular planes [30]. The subcutaneous “danger zone”
for gluteal fat grafting has been dened as a triangle demarcated by the posterior superior iliac spine, the greater trochanter, and the ischial tuberosity [31]. Ordenada et al.
described the vascular anatomy of the gluteal region on fresh
latex-injected cadavers, reinforcing the danger of injecting in
the deeper and more medial planes of the gluteal region [31].
Ghavami etal. dened the ligamentous anatomy of the gluteal region; they shared surgical techniques to strategically
release these ligaments to allow expansion of the subcutaneous plane while leaving certain ligaments intact to prevent
fat injection in the region of the sciatic nerve and large gluteal veins [32]. Alvarez etal. continued to build on this work
by investigating optimal cannula positioning. In a fresh
cadaver study, the incidence of “complications,” dened as
fat found in contact with a neurovascular bundle and/or
within the gluteus muscle, was investigated with various cannula angles and entry locations for gluteal fat injection: the
highest rate of complication was associated with inltration
at an angulation of −30°, 0°, and +15° through the middle
lower gluteal sulcus [33].
There have been numerous reports and innovations to
support safe and effective injection techniques. Delvecchio
et al. described their expansion vibration lipolling technique (roller pump-propelled fat) for gluteal fat grafting in
the subcutaneous plane [34]. Their series demonstrated
safety in over 2419 consecutive cases with an average fat
injection volume of 1000cc and reported no cases of fat
embolism or death. Wall et al. further demonstrated the
safety of power-assisted lipolling in a cadaveric study
while measuring changes in pressure during injection; they
were able to demonstrate that fat does not simply migrate
into the subfascial or muscular plane when the fascia is
intact [35]. Ghavami etal. described their technique using
manual fat injection into the subcutaneous plane using 60cc
Toomey syringes, asserting the safety benets of manual
feedback/resistance to injection, and warning that the use of
automated systems requires extensive surgical experience to
avoid inadvertent injection of large volumes of fat into
incorrect planes [32]. Cansancao et al. have proposed the
use of real-time ultrasound assistance when grafting to
ensure that they remain in the subcutaneous plane during
grafting; they found that this only added 25min to the surgical time [36]. A separate prospective study performed by
Cansancao etal. demonstrated that gluteal fat augmentation
in the subcutaneous plane is effective with long-term fat
retention when compared to similar studies reporting intramuscular fat injections [37].
Anesthesia modications for this procedure have also
been suggested to increase safety. One study suggests that
BBL under oral sedation with tumescent inltration may
offer improved safety, because patients are unlikely to tolerate penetration of the muscle and fascia with the cannula
while awake [38].
Positioning during surgery has also been optimized. To
minimize the risk of either direct cannulation or vein injury
due to traction/tear, studies have shown that the jackknife or
lateral decubitus positions can decrease vein caliber by up to
27% [30].
2.6 BBL Today
Thanks to the expanding body of literature on gluteal fat
grafting and the widely disseminated recommendations of
the ASERF Gluteal Fat Grafting Task Force, the safety prole of gluteal fat grafting has improved greatly. In 2019, a
follow-up survey was sent to members of American Society
for Aesthetic Plastic Surgery (ASAPS) and the International
Society of Aesthetic Plastic Surgery (IASPS) to assess
changes to techniques and mortality in the wake of the
ASERF recommendations. The results showed a dramatic
change in technique. 93.5% of respondents reported they
were aware of the ASERF recommendations. Over 85% of
surgeons inject in subcutaneous fat only, compared to just
39.8% in 2017. Only 4% of surveyed physicians angled their
cannulas down compared to 27.2% just 2years prior. These
changes lead to a profound impact on the mortality rate; it
dropped from an estimated 1in 3448in 2017 to 1in 14,952in
2019, a mortality rate less than abdominoplasty [4, 5].
As some leaders have pointed out, this survey is very
promising yet needs to be taken in context [39]. Surveys are
inherently awed by retrospective bias and cannot be the
basis for denitive conclusions about the safety prole of
this procedure; this makes efforts for objective reporting
databases even more crucial [39]. The American Association
for Accreditation of Ambulatory Surgery Facilities now
mandates the reporting of all gluteal fat grafting cases and
complications [40]. In addition, the General Registry for
Autologous Fat transfer maintains a web-accessible database
which is prospectively gathering outcomes data on this procedure. Survey work by Rios et al. suggests changes are
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D. Sarhaddi et al.
being made; additional database reporting will allow us to
optimize safety in the future [5].
The Brazilian Butt Lift appears to be a success story of
quality improvement, similar to that of liposuction decades
prior. Initially, liposuction raised safety concerns after its
advent in the 1980s. This prompted the creation of a task
force which led to recommendations which improved the
safety of the procedure [41]. We see a similar phenomenon
now with gluteal fat grafting. Through research and concerted effort by professional societies, and continued efforts
by objective reporting agencies, Brazilian Butt Lift Surgery
is safer now than it has ever been. Similar to liposuction, we
can expect this surgery to become a mainstay of aesthetic
surgery and continue to be performed safely for decades to
come.
References
1. The American Society for Aesthetic Plastic Surgery’s cosmetic
surgery National Data Bank: statistics 2018. Aesthet Surg J.
2019;39(Issue Supplement 4):1–27.
2. American Society for Aesthetic Plastic Surgery. The American
Society for Aesthetic Plastic Surgery's Cosmetic Surgery National
Data Bank: statistics 2013. Sage; 2014.
3. Mod MM, et al. Report on mortality from gluteal fat grafting:
recommendations from the ASERF task force. Aesthet Surg J.
2017;37(7):796–806.
4. Keyes GR, et al. Mortality in outpatient surgery. Plast Reconstr
Surg. 2008;122(1):245–50; discussion 251–3.
5. Rios L, Gupta V.Improvement in Brazilian Butt Lift (BBL) safety
with the current recommendations from ASERF, ASAPS, and
ISAPS.Aesthet Surg J. 2020;40:864.
6. Pitanguy I. Trochanteric lipodystrophy. Plast Reconstr Surg.
1964;34:280–6.
7. Gonzalez R, Spina L.Grafting of fat obtained by liposuction: technique and instruments. Rev Bras Cir. 1986;76:243–50.
8. Matsudo PKR, Toledo LS. Experience of injected fat grafting.
Aesthet Plast Surg. 1988;12(1):35–8.
9. Cárdenas-Camarena L, Lacouture AM, Tobar-Losada A.Combined
gluteoplasty: liposuction and lipoinjection. Plast Reconstr Surg.
1999;104(5):1524–31; discussion 1532–3.
10. Roberts TL III, Toledo LS, Badin AZ.Augmentation of the buttocks by micro fat grafting. Aesthet Surg J. 2001;21(4):311–9.
11. Mendieta CG. Gluteal reshaping. Aesthet Surg J.
2007;27(6):641–55.
12. Guerrerosantos J, et al. Long-term survival of free fat grafts
in muscle: an experimental study in rats. Aesthet Plast Surg.
1996;20(5):403–8.
13. Guerrerosantos J.Long-term outcome of autologous fat transplantation in aesthetic facial recontouring: sixteen years of experience
with 1936 cases. Clin Plast Surg. 2000;27(4):515–43.
14. Guerrerosantos J.Evolution of technique: face and neck lifting and
fat injections. Clin Plast Surg. 2008;35(4):663–76.
15. Guerrerosantos J, Haidar F, Paillet JC.Aesthetic facial contour augmentation with microlipolling. Aesthet Surg J. 2003;23(4):239–47.
16. Cárdenas-Camarena L, etal. Deaths caused by gluteal lipoinjection:
what are we doing wrong? Plast Reconstr Surg. 2015;136(1):58.
17. Astarita DC, Scheinin LA, Sathyavagiswaran L.Fat transfer and
fatal macroembolization. J Forensic Sci. 2015;60(2):509–10.
18. Teimourian B, Rogers BW III. A national survey of complications associated with suction lipectomy: a comparative study. Plast
Reconstr Surg. 1989;84(4):628.
19. Che DH, Xiao ZB.Gluteal augmentation with fat grafting: literature review. Aesthet Plast Surg. 2020;45:1633.
20. Gurd AR, Wilson RI. The fat embolism syndrome. J Bone Joint
Surg Br. 1974;56b(3):408–16.
21. Abi-Rafeh J, et al. Comments on "commentary on: the potential
role of corticosteroid prophylaxis for the prevention of microscopic
fat embolism syndrome in gluteal augmentations". Aesthet Surg J.
2020;40(2):Np77–9.
22. Shah B. Complications in gluteal augmentation. Clin Plast Surg.
2018;45(2):179–86.
23. Bayter-Marin JE, etal. Understanding fatal fat embolism in gluteal
lipoinjection: a review of the medical records and autopsy reports
of 16 patients. Plast Reconstr Surg. 2018;142(5):1198–208.
24. Multi-society gluteal fat grafting task force issues safety advisory
urging practitioners to reevaluate technique [letter]. American
Society of Plastic Surgeons (ASPS), American Society for Aesthetic
Plastic Surgery (ASAPS), International Society of Plastic Surgery
(ISPS), International Society of Plastic Regenerative Surgeons
(ISPRES), International Federation for Adipose Therapeutics and
Science (IFATS).
25. Urgent warning to surgeons performing fat grafting to the buttocks (Brazilian Butt Lift or “BBL”) [letter]. American Society of
Plastic Surgeons (ASPS), American Society for Aesthetic Plastic
Surgery (ASAPS), International Society of Plastic Surgery (ISPS),
International Society of Plastic Regenerative Surgeons (ISPRES),
International Federation for Adipose Therapeutics and Science
(IFATS).
26. Nahai F. Acceptable risk: who decides? Aesthet Surg J.
2017;37(7):852–3.
27. The Bottom Line [Press release]. British Association of Aesthetic
Plastic Surgeons.
28. Bapras statement on ‘Brazillian butt lift’ surgery [news and
views]. British Association of Plastic Reconstructive and Aesthetic
Surgeons.
29. Gluteal Fat Grafting Safety Advisory [letter]. American Society of
Plastic Surgeons (ASPS), American Society for Aesthetic Plastic
Surgery (ASAPS), International Society of Plastic Surgery (ISPS),
International Society of Plastic Regenerative Surgeons (ISPRES),
International Federation for Adipose Therapeutics and Science
(IFATS).
30. Turin SY, etal. Gluteal vein anatomy: location, caliber, impact of
patient positioning, and implications for fat grafting. Aesthet Surg
J. 2020;40(6):642–9.
31. Ordenana C, etal. Objectifying the risk of vascular complications
in gluteal augmentation with fat grafting: a latex casted cadaveric
study. Aesthet Surg J. 2020;40(4):402–9.
32. Ghavami A, Villanueva NL, Amirlak B. Gluteal ligamentous
anatomy and its implication in safe buttock augmentation. Plast
Reconstr Surg. 2018;142(2):363–71.
33. Alvarez-Alvarez FA, González-Gutiérrez HO, Ploneda-Valencia
CF.Safe gluteal fat graft avoiding a vascular or nervous injury: an
anatomical study in cadavers. Aesthet Surg J. 2019;39(2):174–84.
34. Del Vecchio D, Wall S Jr. Expansion vibration lipolling: a new
technique in large-volume fat transplantation. Plast Reconstr Surg.
2018;141(5):639e–49e.
35. Wall S Jr, et al. Subcutaneous migration: a dynamic anatomical study of gluteal fat grafting. Plast Reconstr Surg.
2019;143(5):1343–51.
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36. Cansancao AL, et al. Real-time ultrasound-assisted gluteal fat
grafting. Plast Reconstr Surg. 2018;142(2):372–6.
37. Cansancao AL, etal. Subcutaneous-only gluteal fat grafting: a prospective study of the long-term results with ultrasound analysis.
Plast Reconstr Surg. 2019;143(2):447–51.
38. Chia CT, et al. “Brazilian Butt Lift” under local anesthesia: a
novel technique addressing safety concerns. Plast Reconstr Surg.
2018;142(6):1468–75.
39. Nahai F.No “quick x” for this: an update on the Brazilian Butt
Lift. Aesthet Surg J. 2020;40(8):928–30.
40. Ambulatory, A.A.f.A.o. and S.Facilities What is patient safety data
reporting.
41. Iverson, R.E., D.J.Lynch, and A.C.o.P.S. the, Practice advisory on
liposuction. Plast Reconstr Surg, 2004. 113(5), 1478.
Large Volume andCombined Fat
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Grafting Surgery inPostbariatric
Patients: Safety Profile
FrancoBassetto, LauraPandis, andCarlottaScarpa
Contents
3.1 Autologous Fat Transfer Main Complications (1, 9–13, 17, 18) 17
3.2 Lipolling inBreast Surgery 19
References 20
3
Nowadays, fat grafting has become one of the most required
treatments for improving body contouring, and there are
many possible applications either alone or in combined surgery, for example, we can combine it with Brachioplasty,
Facial Lifting, and Buttock Lift.
In the last two decades, the improvement in fat grafting
storage and technique brought to the fore this treatment; the
soft and natural texture of the adipose tissue plus its versatility
and the presence of adult-derived stem cells (ADSCs) have
made lipolling the ideal ller especially in patients who are
characterized by a “weak tissue” as postbariatric ones.
Adipose tissue has been considered inert for years, but
recently scientists have noticed its potential in terms of
regenerative effect, due to the presence of ADSCs which
have shown the capability to self-renew and the same multilineage differentiation potential of other MSCs, and in
releasing adipokines (such as leptin), cytokines (such as
IL6), and many growth factors (such as vascular endothelial
growth factor or transforming growth factor β), which can
contribute, for example, to cell proliferation and communication, motility, and epithelial to mesenchymal transition
(EMT).
Indeed, if on one side fat grafting can be used to improve
volume, on the other side the adipose-derived stem cells can
have a regenerative effect stimulating both the neoangiogenesis and the differentiation and proliferation of cells ameliorating the tissue’s quality.
F. Bassetto · L. Pandis · C. Scarpa (*)
Clinic of Plastic and Reconstructive Surgery, Department of
Neurosciences, University of Padova, Padova, Italy
e-mail: franco.bassetto@unipd.it; carlotta.scarpa@unipd.it
Even if it’s considered a low invasiveness surgery, lipolling can present complications; some are in common with
other treatments, others specic. Here we’ll analyze the most
important ones.
3.1 Autologous Fat Transfer Main
Complications (1, 9–13, 17, 18)
• Infection (Fig. 3.1): rare event, this complication can be
due to a severe contamination of the non-vascularized fat
during the harvesting or grafting procedure. In order to
avoid this complication, a sterile technique is required
and preoperative antibiotic treatment is mandatory.
Postoperative antibiotic treatment can be proposed in par-
ticular to patients who can be predisposed to infection, as
diabetic patients, or in patients treated with steroids, or in
case of overt infection.
• Absorption (Fig.3.2): ranged from 0 to 70%, this compli-
cation can be due to a wrong technique in which damaged
or bloody fat tissue or fat derived from brous areas (e.g.,
upper abdomen) has been used. In order to avoid this
complication, both an overcorrection of 30–50% and a
gentle manipulation of the fat especially during the graft-
ing step can be useful. Small parts and a subcutaneous
inltration are preferable.
• Excessive augmentation: different from the “recom-
mended standard” overcorrection, this event can provoke
important compression of a vein and/or nerves especially
when performed on face/neck or extremities.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A. Di Giuseppe et al. (eds.), Fat Transfer in Plastic Surgery, https://doi.org/10.1007/978-3-031-10881-5_3
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Fig. 3.1 Infection after lipolling and breast implant
ab
F. Bassetto et al.
Fig. 3.3 Skin necrosis followed by dehiscence after liponecrosis
Fig. 3.2 (a) Breast lipolling; (b) fat absorption at 3months
• Fat necrosis with or without skin necrosis and oil cysts/
calcication (Fig.3.3): due to infection and/or overcor-
rection, this complication can lead to oil cysts and/or
calcication requiring surgical treatment to remove
them. If associated with skin necrosis, it could be possible to associate advanced therapies (e.g., negative
pressure therapy) to promote skin healing. If cysts are
small, it can also be possible to aspirate them or treating
them with triamcinolone injection. As we’ll see later,
particular attention is required to avoid misdiagnosis,
especially in breast lipolling. Indeed, small calcica-
Fig. 3.4 Closed incision negative pressure therapy
tions could be misdiagnosed as malignant calcication
to an “inexperienced eye.”
• Asymmetry: due to different fat absorption and/or incorrect technique, this complication can require surgical
treatment as lipoaspiration or new fat transfer.
Postoperative external garments are recommended to prevent it.
• Embolism: extremely rare event, this complication is due
to an incorrect technique that brings to a direct injection
of fat in vessels. If not recognized or treated, it can bring
patients to death. In order to avoid it, sharp needles are not
allowed and it is recommended to graft small fat particles
(2mm or less in diameter).
• Other complications: if lymphatic circulation is compromised due to a fat compression in overcorrected patients,
persistent edema can also occur. To avoid it, external garments, closed incision negative pressure therapy (Fig.3.4),
and an antiedemigen treatment can be recommended.
3 Large Volume andCombined Fat Grafting Surgery inPostbariatric Patients: Safety Prole
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3.2 Lipolling inBreast Surgery
As said earlier, lipolling in breast surgery has been one the
most debated issues of the last decades.
Mammary ptosis means progessive breast drop following
lost of volume as in post bariatric condition breast often requesting a mastopexy and breast implant with following cases of capsular contracture and reintervention due to the presence of a
foreign body that can chronically stimulate immunity system.
Currently, to avoid this complication, surgeons can
perform:
1. A mastopexy plus auto-augmentation: in this case, the
mammary glandula works as a prosthesis. In order to
obtain this result, many are the reported techniques, such
as the “Rubin technique or DSPRM mastopexy” during
which the surgeon performs a combination of parenchymal reshaping, dermal suspension, and
auto-augmentation.
2. Fat transfer: in this case, large volume of fat can substi-
tute prosthesis.
Proposed in 1987 by Bircoll, this last technique brought
many doubts regarding safety prole and different oncological issues have been raised.
There are three main topics: (1) the possible clinical and
instrumental misdiagnosis of cancer due to grafted adipose
tissue calcication and/or oil cysts [2–8]; (2) the inuence on
cancer cells’ proliferation due to the stimulation of neoangiogenesis, and the reported cross-talking between the cancer cells and the adipose stem cells which can be “educated”
and brought to the “dark side”; (3) the aromatases present in
adipose tissue which could stimulate cancer onset or
differentiation.
3.2.1 The Misdiagnosis
Since the 2000s many authors have faced this issue but only
recent systematic reviews and the Expert Consensus Panel
have started to dispel any doubts [2–7, 14–16]. These papers
report radiological changes in a total of 12% of the patients
treated with lipolling, and only 3.2% of the patients need a
biopsy to exclude malignancy [8]. They also underlined that
these changes are easily distinguishable from malignant ones
due to their morphology and localization and they have to be
referred to as fat necrosis, benign calcication, and oil cysts.
Furthermore, if radiological changes after fat transfer are
compared with the ones after breast reduction, it’s possible
to note that the second ones are more frequent.
The authors concluded that a regular follow-up is enough
for these patients and that FNAC can be done if in doubt, and
no signicant risk of misdiagnosis is present.
3.2.2 The Inuence onCancer’s Cells
andthePossibility ofa“Bad Education”
oftheADSCs
This eld has been more debated [3–6] because of recent
researches that notice the capability of fat to inuence angiogenesis promoting cancer onset or evolution and an invitro
possibility to stimulate cancer cells or being stimulated by
cancer cells to differentiate in malignant cells. None of the
above sentences have been demonstrated in vivo. Many
papers reported no increased cancer in patients treated with
lipolling compared to healthy controls. If the patient has a
positive familiar or personal history of breast cancer or there
is a suspicious calcication on preoperative exams, for
example, mammography and/or ultrasounds, it’s better to
refuse fat transfer treatment.
3.2.3 The Aromatases
Aromatases are known to synthesize estrogen and to be
overexpressed in breast cancer tissue. It’s also known that
aromatases are present in adipose tissue and that can be
overexpressed during inammation. Based on these claims,
scientists wondered whether adipose tissue could arise or
stimulate the evolution of estrogen-dependent breast
cancer.
To answer this question, it’s necessary to consider where
the adipose tissue is injected. As Rigotti, Fraser [20, 21], and
other authors already noted, breast lipolling is featured by
grafting both in subcutaneous tissue and the layers under the
glandula rather than into the parenchyma, thus reducing the
risk of rising cancer. Finally, recently a new hypothesis has
been published by Zocchi etal. [2] about the possibility of
wasting aromatases during fat grafting procedure. The
authors indeed suggest that aromatases could be mainly contained in the oily fraction of the adipocyte. Considering that
after completing centrifugation, decantation, or mechanical
lipocondensation, the superuous parts, such as the oil one,
are discarded before inltrating, it should therefore be possible to also discard most of the aromatases contained in the
fat tissue, avoiding or drastically reducing the oncological
risks. Further studies are required to verify this hypothesis.
A nal question was raised a few years ago about a direct
relationship between a large amount of fat transfer and cancer danger [19]. Again, the clinical studies have shown no
relationship [4–6].
In light of the considerations mentioned above, nowadays
it’s fair to state that fat transfer is a safe and less invasive
procedure in postbariatric breast surgery. However, when
breast lipolling is performed, a regular follow-up with
mammography and/or ultrasounds is recommended both
before and after surgical procedures.
20
https://t.me/medicina_free
F. Bassetto et al.
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