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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_577_Библиотеки_им_академика_М_И_Перельмана
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A. Di Giuseppe and F. Giovagnoli
a
e
bcd
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Fig. 20.29 This is a 32-year-old patient, 78kg of weight, 158cm height. A large VASER liposuction was performed, removing 5L of emulsied
fat. Liposuction was extended also to abdomen and anks. Pre op (a, c, e, g), 6months post op (b, d, f, h) oblique view
20.8 Complications
Complications of thighs liposuction have been already discussed in chapter “Body fat grafting contouring in female
patient.”
Essentially they relate to irregularities, depression: management of complication has been discussed in the mentioned chapter.
4. Shiffman MA, Di Giuseppe A.Body contouring. Art, science, and
clinical practice. Springer, Berlin Heidelberg; 2010.
5. https://soltapracticeproposal.com/product- information/products/
vaser- system/.
6. Shiffman MA, Di Giuseppe A.Liposuction. Principles and practice.
Berlin Heidelberg: Springer; 2016.
7. Shiffman MA, Di Giuseppe A.Contorneado corporal. Arte, Ciencia
y Practica Clinica. Amolca; 2013.
8. Di Giuseppe A, Giovagnoli F, Di Giuseppe S, Ronconi D.Vaser
body contouring achieving a more dened shape. The art of body
contouring. London: IntechOpen; 2019. p.105–122.
References
1. da Vinci L.Vitruvian Man 1487. Gallerie dell’Accademia, Venice,
Italy.
2. da Vinci L.Drawing human body proportion 1490. Windsor Castle,
UK.
3. Illouz GI. Anatomic zone of adherence. Annual meeting of The
American Society. Plast Reconstr Surg. 1982;
Breast Augmentation withFat. Patient
https://t.me/medicina_free
Selection andGuidelines
AlbertoDi Giuseppe andFedericoGiovagnoli
Contents
21.1 Introduction 301
21.2 Donor Area 302
21.3 Oncology 305
21.4 Breast Initial Volume (Figs.21.3, 21.4, and21.5) 305
21.5 Preferred Fat Transfer System 306
21.6 Breast Shape 311
21.7 Contraindication 313
References 314
21
21.1 Introduction
Quality of aesthetic result in plastic surgery mostly derives
from proper selection of patient indication.
Limitations are often more important, even to avoid to
select patient with poor indication to the type of surgery
selected. First limitation, in breast augmentation with fat
transfer, is given by the amount of the donor sites.
Structural fat grafting started in 1895 with Czerny [1]
who transplanted a lipoma to reconstruct a breast defect.
Lexer [2] used resected fat to treat bilateral breast defects.
Because of the limited success achieved with these techniques, they were abandoned.
After liposuction was introduced in 1983 by Illouz [3]
and Fournier [4], the idea of removing a good amount of fat
from an area offered to surgeon a new opportunity to use fat
as a potential source of an autologous ller.
Initial poor results were due to poor understanding of
technique needed to harvest properly fat and to transfer to
recipient area.
A. Di Giuseppe (*)
University of Padova, Padova, Italy
F. Giovagnoli
University Vita-Salute San Raffaele, Milan, Italy
In 1987, Bircoll [5, 6] presented a paper regarding the
utilization of autologous fat for breast augmentation.
The American Society of Plastic Surgeons (ASPS) wrote
a position paper as an ad hoc committee on new procedures
issued an opinion that fat grafting to the breast could interfere with breast cancer detection and therefore not be performed [7].
As a result, the fat grafting procedure was condemned for
the potential risk with any scientic evidence. As a consequence, to follow there was a world-wide moratorium to fat
grafting to breast.
In 2007, Coleman [8] published a review of 17 patients
who underwent structural fat grafting to breast and were followed with serial photography. Results were successful, and
the author could show that the overall quantity of the fat
transferred was maintained over a 7–12 years follow-up
time. Coleman utilized syringe technique to transfer signicant volume of fat in a single session.
To follow, Baker and Khouri [9] suggested to inject
smaller volumes of fat in serial grafting sessions, in a preexpanded recipient breast. This latest technique seemed to
work nicely on a very small breasted woman with cup A or B
initial volume. As the nal result is proportioned to the initial
condition, a 100mL fat volume transferred could make a real
difference in a cup A or B patient, and on the contrary be
undetectable in a C, D cup, or even bigger breast size.
© 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_21
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A. Di Giuseppe and F. Giovagnoli
A remarkable amount of different studies emerged
between 1987 and 2007 from mostly Italy (Zocchi 2005
[10], Grisotti 2006 [11]), Rigotti 2007 [12]), and France
(Delay 2005 [13]). Those scientic paper reported experience on fat grafting for breast augmentation (Zocchi), breast
reconstruction (Grisotti), for the treatment of radiation damage to the chest wall and reduction of breast capsule contracture (Rigotti), and nally on soft tissue coverage of breast
implants.
Position in North America has been always more cautious
than in Europe, Japan, and China: in 2008–2009, the Plastic
Surgery Education Foundation (PSEF) and the American
Society of Aesthetic Plastic Surgery (ASAPS) nally published in the ofcial journal Plastic and Reconstructive
Surgery a new statement which sounds as follow: fat grafting
may be considered for breast augmentation and correction of
defects related with medical conditions and previous breast
surgeries; however, results are dependent on technique and
surgeon expertise. Fat grafting to the breast could potentially
interfere with breast cancer detection: however, no evidence
was found that strongly suggests this interference could lead
to confusion and wrong diagnosis. Radiological studies suggest that imaging technologies (ultrasound, mammography,
and MRI) can identify the grafted fat tissue, microcalcications, and suspicious lesions, and biopsies may be performed
if needed for additional clarication.
After this statement, the use of fat for breast enhancement
and reconstruction has been accepted worldwide and is now
constantly practiced.
21.2 Donor Area
Ideally, the desire of any patient is to remove fat from undesired, stubborn area of fat deposits, and transfer into poorly
shaped breast, lacking volume, and projection. However, a
potential complication of any technique of liposuction could
be overaspiration and creation of deformities of the donor
sites.
Large amount of fat should be generally harvested in
order to obtain proper quantity of fat, suitable for transferring and increasing breast aesthetics. Patient with previous
liposuction could be missing adequate quantity of donor fat.
Thin patient, on the other hand, could be either lacking
enough fat volume to give a satisfactory augmentation.
In my experience, by using VASER ultrasound system
and the REVOLVE™ harvesting system, we can obtain 300–
350mL of pure fat, ready to transfer, by emulsifying around
1000 mL of fat, after tumescent inltration. It means that
around 3500 mL of emulsication is needed to acquire
between 800 and 900mL of harvested fat, in order to obtain
a 2 cup size increase in each breast.
In clinical practice, this will require multiple area liposuction, as abdomen, anks, posterior trunk, external thighs, of
circumferential thighs. Knees and arms contain minimal
amount of fat, and they do not increase signicantly the nal
result (Figs. 21.1 and 21.2). Two typical cases of patients
undergoing breast fat transfer are shown in the underlying
photos.
From the rst patient, a total of 400mL of pure fat was
obtained, mainly from abdomen and anks. This patient has
no further good area of fat excess for transferring. A 400mL
of total fat harvested, will result in 200mL for side breast
increase, which means from an A cup to a B/C cup size
increase.
In the second case, in a heavier patient, 950mL were harvested from abdomen, anks, and trunk. 475mL for side will
mean around 2/3 cup size increase.
Those parameters are my guidelines to forecast the nal
volume of breast increase in clinical situation, which is in
proportion with initial breast volume size. In clinical practice, I do use pre- and post-op photos of other treated patients,
to show the nal volume increase that the patient is going to
achieve: this is important to verify patient expectations and
eventually reject those unsuitable for this technique, as in the
case of lack of proper amount of donor fat, to achieve the
result they do want.
ab
cd
ef
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Case 1
Fig. 21.1 400mL of pure fat
harvested from upper lower
abdomen and lateral anks.
Pre op (a, c, e). Post op
6months (b, d, f)
303
304
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cd
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Case 2
Fig. 21.2 950mL of pure fat
harvested from upper lower
abdomen, anks, and trunk.
Pre op (a, c, e). Post op
6months (b, d, f)
A. Di Giuseppe and F. Giovagnoli
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305
21.3 Oncology
Similarly to breast augmentation with implants, any patient
undergoing breast fat transfer must have a proper initial consultation regarding her breast health condition.
Palpable lump, masses, brocystic condition, postpartum
important variation of the breast consistency, past medical
family history of strong hereditary breast cancer, and irradiated breast: all those suspicious conditions must be investigated before undergoing any breast surgery, which will
involve an implant of fat transfer.
GP (General Practitioner) and breast clinic are normally
monitoring breast clinical situation of all patients in many
occidental countries where a national health system (NHS)
does follow on a regular base breast conditions of patients
(the UK, Germany, France, Italy, Spain, etc.).
Radiological studies are requested in those suspicious
patients: ultrasound scan is the simplest, not invasive test
required. Further investigations could require mammograms
or MRI.
In case of doubt, biopsies could be performed to check
breast pathologies.
I will exclude from a breast enhancement with fat, any
patient with suspicious breast lump, cyst, major brocystic
disease, calcications with diagnostic doubt. I do regularly
ask the opinion of a senologist or an oncologist, or the GP
himself, when there is a case with an unclear pattern of breast
morphology.
For years, plastic surgeons were worried to use fat grafting for breast because of the speculation that transplanted fat
might die and cause lumps or calcications that would interfere with the detection of breast cancer.
Bircoll’s paper reported more than 600 breast fat transfer
cases with a calcication rate of 1.4%. I did monitor the rst
200 cases I performed with breast fat transfer with pre- and
post-op ultrasound scan, at 1–3 years interval, with the
supervision of a senologist of the university department of
radiology of my University. Suspicious cases were further
sent to an oncologist for a second opinion.
Most of the patients even with a small aliquot of fat
transferred in each pass can necrose and develop small fat
cyst and calcication. Those small calcications are
benign, can be easily detected by a radiologist as they
appear small and numerous. The calcication connected
with breast cancer, are typically more dense, larger, and
less numerous.
The simple appearance of calcication does not imply an
increase of breast cancer risk.
Cancer detection is the safety issue and not the incidence
of calcications.
Safety guidelines, according to National Breast Cancer
Organisation, do include now fat grafting to breast as a standard approved procedure which must be monitored overtime.
By patient herself, with self-examination, by regular check
by a physician, GP or senologist, and by planned mammograms on a 1-year or 5-year interval.
Mammograms are the favorite test by radiologist for differentiation of cancer from benign lesions of the breast.
Ultrasound and MRI are less invasive and traumatic (MRI
signicantly more expensive).
Fat transfer has been utilized in the past decade in breast
reconstruction after cancer removal. Indications were: asymmetry after lumpectomy, hybrid fat transfer in combination
with implant reconstruction, and unique breast reconstruction with fat in multiple stages. Those arguments are due to
be treated by other authors in this book.
21.4 Breast Initial Volume (Figs.21.3, 21.4,
and21.5)
Fig. 21.3 Cup A
Fig. 21.4 Cup B
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A. Di Giuseppe and F. Giovagnoli
Fig. 21.5 Cup C
21.5 Preferred Fat Transfer System
In the past 4 years, I used the REVOLVE™ system by
LifeCell.
An integrated, high-volume fat processing system
designed by adipose transplantation pioneers and founders
of the International Federation for Adipose Therapeutics and
Science.
It is an autologous fat tissue (AFT) collection device and
tissue delivery system. It collects autologous adipose tissue
and rapidly washes and delivers the tissue for body
contouring.
REVOLVE™ System is a sterile single-use disposable
tissue canister used for harvesting, ltering, separating, concentrating, and transferring autologous tissue components
for reintroduction to the same patient during a single surgical
procedure for repair, reconstruction, or replacement of integumentary or musculoskeletal tissues.
For additional volume of tissue, canister may be lled and
emptied a second time during the same surgery on the same
patient.
It is an all-in-one closed system, for harvest, lter, active
wash, and remove strands.
Mesh lter designed to lter and strain lipoaspirate during
the harvesting phase and active mechanical washing
process.
It rapidly removes tumescent, reduces cell debris, eliminates free oil, and nally concentrates adipose tissue
(Fig.21.6).
Fig. 21.6 REVOLVE™ system (Courtesy LifeCell Corporation, an
AbbVie company. © 2021 AbbVie. All rights reserved)
The system contains a propeller for active washing, it
does enhances washing process for high-quality fat and
removes collagen strands to minimize injection syringe
clogging.
Fat is extracted by syringes. It is possible to direct load
syringes for injection from canister to minimize steps.
Extraction with catheter tip or luer lock syringe is performed (Fig.21.7).
The system is a high-volume fat processing system: it
processes up to 700mL of lipoaspirate in less than 10min. It
is easier to use, requiring fewer steps to process large quantities of adipose tissue.
It can control critical fat grafting variables and is sterile,
single-patient, disposable device.
It is a closed system that minimizes tissue handling and
exposure to outside air. It can control critical fat grafting
variables and is sterile, single-patient, disposable device.
Clinical result shows that REVOLVE™ system processed a higher percentage of adipose tissue compared
with the two other methods: decantation and centrifugation. It yielded signicantly less blood cell debris and a
lower percentage of free oil. It has signicantly higher fat
graft retention (73.2%) than decantation (37.5%) and similar to centrifugation (67.7%) and maintained fat in physiological conditions (pH and osmolality) (Figs. 21.8 and
21.9).
Breast initial volume is the parameter of reference to plan
fat enhancement.
100
System
PERCENT %
UEOUS
PERCENT % WEIGHT RETENTION
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307
In Fig.21.3, an A cup patient is shown. Potentially this
patient could arrive at a maximum of a B/C cup nal result,
minding an average of 200 ml of fat transferred for side,
which is the average of donor area achievable.
In Fig. 21.4, a B cup patient is shown. Potentially this
patient could arrive at a maximum of a C/D cup nal result,
minding an average of 300–350 mL of fat transferred for
side.
Fig. 21.7 REVOLVE™ system syringes for extracting fat (Courtesy
LifeCell Corporation, an AbbVie company. © 2021 AbbVie. All rights
reserved)
In Fig. 21.5, a C cup patient is shown. Potentially this
patient could arrive at a maximum of a D/DD cup nal result,
minding an average of 450–500 mL of fat transferred for
side.
In the past, I used the Crisalix Virtual 3D and 4D imaging
system for planning and showing patient a potential result of
a breast enhancement with fat. This system is well known
and utilized worldwide for breast augmentation and other
body contouring and facial procedures. Of course there are
few other systems on the market with similar characteristics.
I did abandon the system, as 3D or 4D image result is less
natural than the real one I will achieve eventually after
surgery.
When I discuss nal volume achievable, I normally state
as follow:
1. Fat absorption rate is around 20% of the volume trans-
ferred, minding the technique utilizes VASER system and
REVOLVE™ harvesting device (350€ cost for a single
device).
2. Patient does not compress enhanced breast with strong
compression bra. Fat does not like compression that will
eventually lead to necrosis and absorption. A light bra is
necessary in the post-op period.
Fig. 21.8 REVOLVE System
minimized potential
inammatory response for
transplanted tissue by
signicantly removing red
blood cells, fatty acids and
debris (Courtesy LifeCell
Corporation, an AbbVie
company. © 2021 AbbVie. All
rights reserved)
Fig. 21.9 Higher fat graft
retention than decantation and
similar to centrifugation
(Courtesy LifeCell
Corporation, an AbbVie
company. © 2021 AbbVie. All
rights reserved)
80
60
40
20
100
80
60
40
20
* P<0.05
FAT
79%
72%
59%
0
0
21%
REVOLVE
73.2%
RSD-
20%
n-79
TM
8%
Decant
Method
P<0.05
33%
37.5%
RSD-
35%
n-77
20%
Centrifugation
8%
OIL
AQ
67.7%
RSD-
25%
n-80
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A. Di Giuseppe and F. Giovagnoli
3. Fat transferred must be preserved at list for the rst
3months after surgery, until the process of full revascularization is completed. This will mean no diet, no burnout, and gym exercise as well.
Maintaining volume in the future will depend on this
main factor: weight maintenance over time.
It is clear that any signicant variation of weight, in terms
of losses, will determine a partial or total loss of the transplanted fat, as well as a fat reduction all over the body, affecting the external fat and or the visceral fat.
Hormonal changes, as due to menopause or pregnancy,
could affect as well the nal volume maintenance.
I make sure that the patient is fully aware of those potential changes connected with weight changes and hormonal
variations, which are totally independent from surgical technique and surgeon skill.
First case (Fig.21.10) is the A cup breast size that turned
into a full B/small C cup after 235 mL per side of fat
transferred.
Second case (Fig. 21.11) is the B cup breast size that
turned into a full C/small D cup after 360mL per side of fat
transferred.
Third case (Fig.21.12) is the C cup breast size that turned
into a full D/DD cup after 400 mL per side of fat
transferred.
First case
Second case
Third case
Another excellent indication for fat transfer to breast is in
volume asymmetry, or in correcting secondary cases.
Fourth case is a patient of 30years age, who underwent,
when 18years, a mastopexy. She ended up with a volume
asymmetry and a mild asymmetry in shape. Patient underwent breast fat augmentation, and 500mL and 550mL of fat
were transferred. Note the good symmetry achieved in the
8months post-op follow-up. Final volume was a DD/E cup
starting from an asymmetrical B cup size (Fig.21.13).
Fourth case
In the fth case, another example of volume asymmetry
after mastopexy and implants is presented. Thirty-two-yearold woman, who had two mastopexy and implants, with two
different surgeons. Despite a decent result was achieved, she
was still complaining for missing cleavage at the inner side
of both breast, with asymmetry, and diverting nipples. In this
case, plan was to ll the inner and upper quadrants, to fulll
patient expectations, which were quite high. Instead of
changing again breast implants, which could cause further
gravity and lateralization of breasts, solution was to transfer
250 mL of fat mainly to the inner quadrants to improve
cleavage and fullness of the top (Fig.21.14).
Fifth case
abc
de f
Fig. 21.10 A cup breast. Pre op (a, c, e), post op 6months after 235mL per side fat transferred (b, d, f). Full B/small C cup achieved
21 Breast Augmentation withFat. Patient Selection andGuidelines
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ab c
de f
309
Fig. 21.11 B cup breast. Pre op (a, c, e), post op 6months after 360mL per side fat transferred (b, d, f). Full C/small D cup achieved
abc
def
Fig. 21.12 C cup breast. Pre op (a, c, e), post op 6months after 400mL per side fat transferred (b, d, f). Full D/DD cup achieved
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