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A. Di Giuseppe and F. Giovagnoli
Fig. 21.13 Breast volume asymmetry after mastopexy, B cup size, pre op (a, c, e). Post op 6months after 500 and 550mL of fat transferred (b,
d, f) to improve symmetry. DD/E cup size achieved
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Fig. 21.14 Breast volume asymmetry after mastopexy, missing cleavage, and top fullness, C/D cup size, pre op (a, c, e). Post op 6months after
250mL of fat transferred (b, d, f). D/DD cup size achieved. Cleavage improved
21 Breast Augmentation withFat. Patient Selection andGuidelines
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21.6 Breast Shape
Breast shape, breast position, and aging are all factors that
will inuence the indication for breast fat transfer.
With fat, it is impossible to achieve the same volume of an
implant as the nal result depends on the total volume of fat
that can be harvested from patient.
Fat has a different consistency in comparison with silicon:
it is softer, cannot achieve same projection of an implant.
Careful selection of patient is mandatory in order to avoid
misunderstanding and complain from patient, concerning the
goals achieved or the targets not achievable.
Breast initial position and shape is another factor that
inuences patient selection. Initial nipple position should not
be exceeding 22cm from middle clavicle.
The sixth case is a 32-year-old patient with emptiness of
the top quadrants of the breast, post pregnancy, and lactation.
She had 250 ml of fat transferred on each side, nearly
positioned on the upper quadrants to ll the loss of volume
(Fig.21.15).
Sixth case
The seventh case is a 40-year-old black woman, with
breast ptosis and loss of top fullness after breast feeding.
Nipple initial position was located at 22cm from midclavi-
cle. This is still a good indication for fat transfer, minding
that patient is looking for a natural result, with improved
upper quadrant volume, but no change in projection and
position of the nipple. 320mL of fat was transferred bilaterally (Fig.21.16).
Seventh case
Aging is the last factor to consider in the patient selection.
Skin texture, nipple position, and skin redraping capability
are the factors that could limit indications.
Middle-aged women would rather prefer a natural looking result and a mild volume increase, in order to restore
general breast volume lost by progressive atrophy, due to
menopause and hormonal changes.
In my experience, those patients are nally happier than
the younger population, as their expectations are lower.
Eighth case shows a 62-year-old woman, with still good
skin tone, good positioning of the NAC nipple areolar complex, and a generalized atrophy of all breast (A/B cup size).
250mL of fat were transferred bilaterally. One-year post-op
photos show that overall nice result has been achieved, with
natural outcome, and even improved skin texture, probably
due to stem cell regenerative capability of neovascularization
(Fig.21.17).
Eighth case
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Fig. 21.15 Breast volume C cup size, mild ptosis, and emptiness of the upper quadrants. Pre op (a, c, e). Post op 6months after 250mL of fat
transferred (b, d, f) transferred mainly on the upper quadrants
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A. Di Giuseppe and F. Giovagnoli
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Fig. 21.16 Breast ptosis 22cm from midclavicle and post pregnancy lack of volume on top quadrants, C cup size, pre op (a, c, e). Post op
6months after 320mL of fat transferred (b, d, f) mainly to upper quadrants to improve fullness
f
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Fig. 21.17 62-year-old patient with breast atrophy after menopause. Pre op (a, c, e). Post op 6months after 250mL of fat transferred (b, d, f)
21 Breast Augmentation withFat. Patient Selection andGuidelines
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21.7 Contraindication
Absolute contraindication to breast fat transfer is extremely
skinny patients where donor fat is unavailable. Also patients
addicted to gym work out have a poor indication, as they
might burn out the transferred fat immediately after surgery.
I normally warn patients to refrain from any intense physical
activity for the rst 3months after surgery.
Another obvious contraindication is represented by
patients who are looking for massive volume increase, which
is clearly unreachable with any volume of fat, even if available. Projection of top of breast is another impossible goal
achievable with fat transfer. Patient willing to have top fullness and very rounded breasts should be indicated only for
breast surgery with ultrahigh projection implants.
Otherwise, there will be surely unsatised results
achieved.
One of the mistakes that surgeon could make initially
with breast fat transfer is not to select properly patients. This
case presents a 43-year-old woman with ptotic breast, with
nipple at 23–24cm from middle clavicle and hanging breasts,
with atrophy after weight loss. This lady presents a clear
contraindication for fat transfer, as fat has not the consistency and the ability to lift breast even partially, at might
happen with an implant. In this case, a hybrid breast augmentation and mastopexy could be performed (periareolar of
vertical scar) combining a submuscular implant with fat
transferred to achieve better contour and natural looking
result (Fig.21.18).
Hybrid breast augmentation is a new trend that is rapidly
expanding in the day practice of a plastic surgeon, as it
combines the benets of an implant (consistency, shape, and
projection) with the advantages of softness, naturalness, and
avoiding the typical stigmata of implants in skinny patients
(visibility on top breast, on lateral breast, where muscle is
absent of minimally represented, unnatural appearance in
few instances, tendency to capsule contracture). In those
patients, hybrid breast augmentation does play an important
role (Fig.21.19).
Fat is useful for preventing and treating breast capsule
contracture, as demonstrated by Rigotti [12]. The role of
stem cell in promoting a neo-vascularization of the capsule
around the implant helps softening the interaction between
tissue and foreign body, thus decreasing the strength of the
foreign body reaction.
The action of stem cells works as regenerative agent in
stimulating the growth of a softer capsule, with minor retraction and pain and deformity associated. Fat transfer has been
found to be extremely useful also for releasing severe degree
of capsule contracture (Baker III–IV), thus ameliorating the
overall appearance of the constricted breast, and decreasing
the often associated pain.
However, there is a growing tendency in those days to
accomplish breast fat augmentation with fat transfer, especially in secondary cases, where over the revision surgery,
the surgeon often encounter problems with capsule contracture of the previous implant.
Risk of recurrence of capsule contracture cannot be
underestimated, and the fat transferred could potentially help
preventing the formation of a new tight capsule and a rm
contracture.
Smoothening the interface between implant and soft tissues is another benet which fat transfer can help with: especially in thin patients, or in patient with subcutaneous
thinning, this represents the rst option nowadays.
In the past, plastic surgeon did use alloplastic material, as
porcine-derived mesh, or acellular human tissue matrix,
derived from cadaveric tissue, which exhibits regenerative
Fig. 21.18 Patient with mild ptosis (nipple 23–24cm from midclavicle). Contraindicated for fat transfer
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A. Di Giuseppe and F. Giovagnoli
Fig. 21.19 Hybrid breast augmentation. 250cc moderate plus subpectoral implants and 200mL of fat transferred per side. Post op 6months
properties. All donor cell and allergic epitopes are removed,
leaving a collagen scaffold, growth factor receptors, and vascular channels that aid in tissue regeneration with minimum
scar and brosis.
The acellular matrix generates physiological cues that
mimic the native tissue microenvironment. Acellular dermal
matrix is a soft connective tissue graft generated by a decellularization process that preserves the intact extracellular
skin matrix.
Fat transfer has the capability to vicariate and largely substitute any need for cellular matrix or other porcine- derived
mesh, in cases of thinning of the subcutaneous tissue in the
breast region.
References
1. Czerny V. Plastischer Erzats de Brustdrüse durch ein Lipom.
Zentralbl Chir. 1895;27:72.
2. Lexer E.Die freien Transplantationen, vol. 1. Stuttgart: Ferdinand
Enke; 1919.
3. Illouz YG.Body contouring by lipolysis: a 5-year experience with
over 3000 cases. Plast Reconstr Surg. 1983;72:591–7.
4. Fournier PF, Otteni FM.Lipodissection in body sculpturing: the dry
procedure. Plast Reconstr Surg. 1983;72:610–9.
5. Bircoll M.Cosmetic breast augmentation utilizing autologous fat
and liposuction techniques. Plast Reconstr Surg. 1987;79:267–71.
6. Bircoll M, Novack BH.Autologous fat transplantation employing
liposuction techniques. Ann Plast Surg. 1987;18:327–9.
7. ASPS ad hoc Committee on NewYork procedures. Report on autologous fat transplantation. Plast Surg Nurs. 1987;7:140–1.
8. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited:
safety and efcacy. Plast Reconstr Surg. 2007;119:775–85.
9. Baker DC, Khouri RK. Breast augmentation with Brava external expansion and fat grafting: a prospective study. Presented at
the annual meeting of the American Society of Aesthetic Plastic
Surgery, Orlando, FL, April 2006.
10. Zocchi ML, Zuliani F, Nava M, etal. Bicompartmental breast lipostructuring. Presented at the seventh international congress of aesthetic medicine, Milan, Oct 2005.
11. Grisotti A. Lipostructure, of course in the body and breast.
Presented at the Seventeenth Annual American Alpin Wirkshop in
Plastic Surgery, Sun Valley, Idaho, Feb 2006.
12. Rigotti G, Marchi A, Galiè M, etal. Clinical treatment of radiotherapy tissue damages by lipoaspirate transplant: a healing process mediated by adipose stem cells (ASCs). Plast Reconstr Surg.
2007;119:1409–22; discussion 1423–1424.
13. Delay E, Delaporte T, Sinna R, etal. Breast implant alternatives.
Ann Chir Plast Esthet. 2005;50:652–72.
Total Breast Reconstruction
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with“Deflating Technique”
22
FrancoBassetto andMartinaGrigatti
Contents
22.1 Introduction 315
Bibliography 318
22.1 Introduction
In the treatment of breast cancer, breast reconstruction represents an integral part of the treatment. The alternatives currently available are autologous tissue transfer, such as aps
or fat grafting, implants, or a combination of both.
The breast is a subcutaneous tissue inuenced by gravity,
aging, and posture; for this reason microsurgical tissue transfer represents the rst choice in reconstruction to achieve
long-lasting natural results based on the replace-like-withlike principle. However, this technique requires an experienced surgeon with microsurgical skills, longer
hospitalization, extra scarring, and morbidity in the donor
site. Sometimes for some patients, autologous tissue for a
microsurgical approach is not available or simply not wanted
by all patients.
Alloplastic breast reconstruction with implants generates
fewer scars, no donor site morbidity, and less operating time.
However, it increases the risk of infection, capsular contraction, animation deformity, implant migration, poor aesthetic
results, for example, with a decient lower pole and unnatural contours. Moreover, the challenge with implant-based
reconstruction is the soft tissue coverage.
Lipolling, in the past, is considered dangerous in breast
cancer for its stem properties; however, it is now a univer-
F. Bassetto ∙ M. Grigatti (*)
Department of Neurosciences, Clinic of Plastic Surgery,
Padua, Italy
e-mail: franco.bassetto@unipd.it
sally accepted technique to correct soft tissue deciencies or
to improve contour in breast reconstruction.
In this chapter, we will describe the total breast reconstruction with the “deating technique” after mastectomy.
This method provides a protocol of tissue expansion with
serial deation-lipolling.
Indication The challenge is to compensate the volume
loss after mastectomy, where the skin aps are completely
without support previously provided by Cooper’s ligament
and the breast glandular tissue.
This method could be a choice especially for small to
moderate sized breast patients. It is indicated for motivated
patients who do not want or who cannot have a microsurgical
reconstruction, but who want a natural effect without an
implant (or with one as small as possible).
Technique Different techniques are described in the literature, the concept in common is the breast reconstruction
after mastectomy with fat grafting combined with internal
tissue expansion.
It is a multistep procedure. It starts with the preoperative
marking in the upright position of the dissection limit and the
existing and the new inframammary fold.
Surgery is normally performed under general anesthesia. The expander is placed subcutaneously in a prepectoral position, which is the most rational place as the breast
is a subcutaneous structure. It is inserted through the inframammary fold, while the existing mastectomy scar is left
intact in secondary reconstruction, in order to preserve the
skin envelope and to avoid the scar reopening that would
compromise the lipolling procedure as the wound needs
to heal again.
© 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_22
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F. Bassetto and M. Grigatti
The expander in a deated condition should be placed
lower than the existing inframammary fold to support the
lower pole expansion. A closed suction drain must be placed
in the pocket and removed when the output is minor of 30cc
for 24 h. Antibiotic prophylaxis is also necessary
postoperatively.
Expansion is normally started at 2weeks postoperatively
and performed on weekly basis with saline or air in outpatient setting.
The expansion process generates a well-vascularized capsule, and fat injection is performed in the space between skin
and this capsule.
Eight weeks after the onset of expansion, lipolling with
Coleman’s technique is gently performed, paying attention
not to create excessive tissue turgor, which could compromise fat graft survival. Donor sites are thigh, buttock area,
and abdomen.
The fat grafting could be delayed until 6month after the
end of adjuvant therapy.
Although the traditional concerns regarding fat viability,
especially after radiotherapy, it is demonstrated that injecting
fat after reducing the expander pressure is conductive to its
integration in the recipient site (Fig.22.1).
Lipolling uses lipoaspirate material (liqueed), and it
injects numerous minuscule particles of fat at different levels
to maximize the surface area of contact between the fat graft
and the recipient site (Fig.22.2).
Diffusion of the fat in the prepectoral pocket is prevented
by the expander and his capsule, which acts as an anchor.
The capsule has a newly generated vascular plexus in the
outer layer, and it represent the support for the fat graft.
Fat grafting is combined with gradual emptying of the
expander during each course (i.e., 50mL of uid removed
and 70mL of fat injected).
In this way, the breast volume remains constant, but the
consistency of the breast changes gradually.
Fat grafting sessions are performed with an interval of
2–3months in a day surgery setting until the result is reached.
At that time, the expander is removed.
Even if this technique allows total breast reconstruction using only fat graft, it is possible, in case of bigger
breast or when more volume is needed, to add a core volume and projection with an implant (smaller than in a
traditional implant- based reconstruction) inserted after
expansor removal to provide extra projection, volume,
and shape.
In this case, implant’s impact in surrounding tissues is
minimized with the restoration of a thick subcutaneous
autologous fat-grafted tissue.
Complications are rare or unsevere. The most frequent
are seroma and hematoma and expander infection.
Advantages The advantages are many. The method is
safe with minimal scar and it requires short minimal invasive
procedures in day surgery or outpatient setting, with a very
simple equipment and low costs. The donor site morbidity is
minimal, and the procedure does not affect the patient function with a minor disruption of patient professional and personal life. The consistency of the breast is natural, and the fat
graft has a positive effect on the mastectomy scar. Finally,
this method allows to convert to breast reconstruction with
an implant at every stage.
Disadvantages The disadvantages are few, but they
are worthy of attention in choosing this technique of
breast reconstruction. This method in fact requires many
procedures, a long-time treatment, so that the patient
must be really motivated. It requires also the right patient,
with an appropriate body structure with a sufficient volume of the donor site for fat grafting. Moreover, another
important disadvantage is the unpredictable fat resorption rate.
Conclusion The rapid restoration of breast volume with
the expander and the gradual change in breast consistency
and shape motivate the patient to continue the treatment and
encourage the return to professional and intimate life.
This fact, together with all the advantages listed above,
make this technique a valid choice of breast reconstruction in
selected patients.
22 Total Breast Reconstruction with“Deating Technique”
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abc
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ghi
317
Fig. 22.1 Sequential reconstruction using fat grafts. Preoperatory images (a–c). Progressive deating of breast expander (d–f). Follow-up after
2years and 3 sessions of adipose tissue grafts (g–i)
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F. Bassetto and M. Grigatti
Fig. 22.2 Sequential reconstruction using fat grafts. Preoperatory images (a–c). Follow-up after 3years and 4 sessions of adipose tissue grafts
(d–f)
Bibliography
1. Sommeling CE, Van Landuyt K, Depypere H, Van den Broecke R,
Monstrey S, Blondeel PN, Morrison WA, Stillaert FB. Composite
breast reconstruction: implant-based breast reconstruction
with adjunctive lipolling. J Plast Reconstr Aesthet Surg.
2017;70(8):1051–8.
2. Stillaert FBJL, etal. The prepectoral, hybrid breast reconstruction:
the synergy of lipolling and breast implants. Plast Reconstr Surg
Glob Open. 2020;8:e2966.
3. Kolasinski J.Total breast reconstruction with fat grafting combined
with internal tissue expansion. Plast Reconstr Surg Glob Open.
2019;7(4):e2009.
Total Fat Grafting Breast Augmentation
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foraHarmonious Reshaping
CaterinaGardener andVincenzoVindigni
Contents
23.1 Introduction 319
23.2 Indications 320
23.3 Before Surgery 321
23.4 Procedure 321
23.5 Postoperative Time 323
23.6 Conclusion 324
References 324
23
23.1 Introduction
Fat grafting in cosmetic surgery is a widespread technique
used for many purposes. Due to its manageability and safety,
fat transfer offers many possibilities and clinical applications, which are more and more expanding.
In the panorama of breast surgery, it represents a valid and
alternative method to conventional silicone implants.
Although breast implants have become indispensable tools
for plastic surgeons, they remain foreign bodies for human
organisms, and they are also associated with several complications and discomfort. Implants can develop capsular contraction, rupture, displacement, infection, and they need to
be changed sooner or later during a lifelong period. Because
of this and because plastic surgeons are always aiming of the
best outcome for each patient, considering his/her expectations and history, fat grafting has become a signicant option.
In particular, breast can denitely improve in terms of size
and shape with autologous fat transfer.
C. Gardener (*) · V. Vindigni
University of Padua, Department of Neuroscience, Clinic of Plastic
and Reconstructive Surgery, Padua, Italy
e-mail: vincenzo.vindigni@unipd.it
A sort of autologous fat transfer on the breast was practiced for the rst time in 1895 by Czerny [1], who implanted
a lumbar lipoma into a breast after mastectomy to avoid
asymmetry. After almost a century, Bircoll was the rst
author in 1987 who described the technique of autologous fat
injection for breast augmentation using liposuction [2].
Several years after, Coleman and Delay introduced the term
“lipomodelling” [3]. Since then fat transfer has been more
and more used both in cosmetic and in reconstructive surgery
to obtain the highest quality results, in order of safety and
effectiveness.
Breast augmentation obtained by autologous tissues has
peculiar features, it is distinguished by a pleasing and anatomical shape, breast results soft to the touch, and it feels
natural and comfortable. Scars are almost invisible and, in
addition, removal of unwanted fat tissue from one part of the
body for enhancement of another represents a captivating
option for patients. For all of these reasons, breast augmentation with lipolling is continuously more requested.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
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