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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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C. Gardener and V. Vindigni
23.2 Indications
Autologous fat grafting is a safe procedure, without risk of
developing an immune response, its technical steps are easy,
and it offers the possibility of being repeated and perfected if
needed.
Because of this fat transfer is characterized by a wide
spread of surgical indications. It is suitable to obtain primary
breast cosmetic augmentation, in patients desiring a modest
increase. Augmentation, for example, also in transfeminine
patients. It can be used to correct congenital or acquired
deformities such as micromastia, tuberous breast (Fig.23.1),
asymmetry, or defects caused by Poland syndrome, to add
volume to the underdeveloped breast. It is important to notice
that this type of conditions represent the ideal recipient tissue, a virgin tissue, with no scars or brosis from previous
surgery.
And it also offers a valid solution to restore volume loss
after implants removal (Fig.23.2).
Fat grafting for lling defects after reconstruction with
implants or aps post breast cancer are arguments of other
chapters of the book.
Fig. 23.1 Pre (up) and postop (down) pictures of a patient affected by breast asymmetry. On the right breast, augmentation with lipolling was
performed, mastopexy on the left side
23 Total Fat Grafting Breast Augmentation foraHarmonious Reshaping
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Fig. 23.2 Removal of breast implants and replacement of lost volume with fat grafting. Before the procedure in 2015 (up) and after the procedure
in 2021 (down)
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23.3 Before Surgery
Before planning fat transfer for breast augmentation, it is
important to evaluate patient’s past medical history, social,
and health status. Surgeons should consider risks and benets of surgery, keeping in mind that lipolling is a procedure
not recommended in smokers or in people affected by bleeding disorders.
It is mandatory also to discuss in depth patient’s goals for
the operation, in order to understand and achieve patient’s
expectations. Breast augmentation reached by this technique
is moderate and not too projected. Promised results must be
obtainable, and they depend on the physical conformation of
the patient. Evaluation of donor areas should be made to predict the degree of correction, being conscious that for one
cupaugmentation an average of 250–400cc of fat per side is
required. In addition, a total of about 200–250cc represent
the traditional upper limit of fat transfer for each mammal;
this limit can be higher if assisted by external expanders [4].
Before surgery patients should bewell informed about the
possible loss of volume due to reabsorption and that their
body contour will change. Because unlike silicone implants,
lipolling results are not so predictable, and patients must
also be warned that multiple procedures should be needed to
achieve a satisfying result. Usually 1–5 sessions are required,
with an average of 3 [5].
Before fat transfer, some surgeons mandate a mammogram or MRI, to both exclude underlying pathologies, to
study anatomy in depth, and to establish a baseline for later
comparison [6, 7].
Learned societies agree on the following points:
– To not perform fat transfer on patients at high risk for
breast cancer
– To conduct preoperative radiological checkup
– To conduct regular postoperative follow-up [8]
23.4 Procedure
For reaching the desired result, a careful evaluation of breast
symmetry and skin quality must be conducted. Unlike silicone implants, this technique allows not only augmentation
of size but also allows to remodel the intermammary distance
cleft, to correct shape asymmetries, and to volumize the
superior medial pole for a better décolleté. But, unlike silicone implants, it is a time-consuming procedure.
The body offers several areas to harvest fat, most useful
and handy areas are lower abdomen, buttocks, and thighs.
Often abdomen can represent a single donor area.
On the other hand, the thigh is less brous, contains less
septae, and has a relatively low blood supply and is therefore
less susceptible to develop postoperative collections [9].
Anyway, it has been noticed that the choice of donor sites
does not affect the survival of the adipocytes [10].
External volume expansion (EVE), as the BRAVA system, has shown to improve results [11, 12] (Fig. 23.2).
Despite the use of BRAVA was not very widespread, neither
its indications were standardized, in past years, it has been an
effective tool for enhancing fat transfer in breast surgery [13]
(Fig.23.3).
Preoperative marking in standing position is fundamental
to ensuresurgery understanding by the patient and the operating team. It is alsoimportant to mark sites of incision with the
patient upright in order to place them in natural body creases.
Most surgeons practice the wet technique and hand suction with blunt tipped cannulae after waiting about 15/20min
to harvest fat. But power-assisted liposuction and lipolling
[14, 15] represent a very useful and practiced option because
they minimize the surgery time.
Once the fat has been collected either centrifugation [6,
16], mechanical decanting, or graft “washing” is needed to
purify it. Particles more than 3mm should not be transferred
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Fig. 23.3 External volume expansion treatment (EVE) before surgery
C. Gardener and V. Vindigni
Fig. 23.4 Fat decanting after harvesting (right), fat injection technique (left)
as this increases the chance of developing necrosis or cysts
(Fig.23.4).
Although the methods of fat harvesting, processing, and
injection all have an impact on successful clinical outcome,
it is described that harvesting and processing have less
impact than the method of injection [17].
In fact, it is fundamental to inject fat meticulously, without haste and taking the necessary time to do it. Fat has to be
placed in very small amounts as the needle is gradually withdrawn, to maximize the surface area to revascularization.
Coleman suggests approximately 0.25 cc of fat with each
ejection of the cannula [6].
Injecting large volumes of fat could jeopardize the vascularity of the graft and cause contour irregularities [3].
To inject fat, small incisions are practiced in the inframammary fold, in natural creases or periareolar for the inner
half [18]. Cannulae should be moved with fan-shaped wide
movements. The fat must be distributed in different layers:
most of it has to be grafted submammarly into the pectoralis
major muscle, which provides volume and projection.
Injection in breast parenchyma enhances overall breast volume, but not too much fat can be grafted at this level to not
compromise graft survival. Placement in more supercial
layers instead allows to control shaping of the breast and to
correct specic deformities [6].
Zocchi described the “bicompartmental grafting technique”: one part of the graft is placed subglandular/prefascial
and the other subcutaneous, avoiding breast parenchyma
23 Total Fat Grafting Breast Augmentation foraHarmonious Reshaping
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[19]. During surgery, it is useful to do a check with the
patient seated at an angle of 45° to enable surgeons to evaluate the symmetry and shape under gravity effect.
Once the graft is distributed and incisions are closed with
sutures, the breast has to be molded with hands using lubricant such as Vaseline [19].
23.5 Postoperative Time
Once surgery is concluded, it is crucial to minimize sheer
forces on the breast to allow engraftment and revascularization of the grafted adipocytes. For this purpose and to provide protection to healing tissues, patients should wear
surgical brasseries day and night.
On donor sites, compressive dressing is usually applied to
prevent seroma and hematoma formation.
The amount of fat injected depends on the indication of
the procedure, but a part of this volume will be lost within
the rst 4–6months. The precise quantity that will be reab-
sorbed is not known and every case is different. For this reason, it is better to wait at least 4 months before a second
procedure of fat grafting if needed (Fig.23.5).
If the procedure is not performed correctly, both early and
late complications can occur. Most common complications
are edema, seroma, swelling, bruising, and infection.
Necrosis of variable portion of the graft is possible, and it
can present as a palpable lump, or more often as an oil cyst
or calcication on mammogram. Late complications can be
contour irregularities, deformation of the donor site, as well
as hypersensitive nipples and breasts [20]. Anyway, most of
complications can be avoided by increasing fat survival rate,
goal obtainable by practicing this procedure meticulously.
Calcications in some cases can interfere with breast cancer surveillance, but no study has shown an increase in the
incidence of breast cancer due to this surgical practice [8].
Most of unsatisfactory results can be avoided by previous
and accurate interviews with patients, who must have been
well informed of the possibility of having to undergo more
procedure to obtain the nal result.
Fig. 23.5 Patient treated with EVE before surgery and transfer of 350cc of fat on the right breast. Before surgery (up) after 1year (down)
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C. Gardener and V. Vindigni
23.6 Conclusion
Fat grafting for breast augmentation is a procedure characterized by high level of patients’ satisfaction [21] and minimal complicationsrate. It offers good cosmetic results with
low costs, and breast will be perceived as its own part of the
body with natural consistency. In addition, it provides secondary benets such as liposuction of desired areas, remodelling patient’s silhouette.
If practiced by expert surgeons, it represents an easy tech-
nique with high level of reproducibility.
The length of surgery time constitutes a major limiting
factor such as a major disadvantage is that in some cases it
could be necessary to repeat the procedureseveral times in
order to achievethe desired result. But if on the one hand, it
is true thatsometimes more interventions may be necessary,
on the other hand, once obtained, results are stable over time.
Patients will not have the problem of implants’ rupture neither the need of implants substitution during lifetime, saving
money and unnecessaryhospitalization.
References
1. Chan CW, McCulley SJ, Macmillan RD.Autologous fat transfer—
a review of the literature with a focus on breast cancer surgery. J
Plast Reconstr Aesthet Surg. 2008;61:1438.
2. Bircoll M.Cosmetic breast augmentation utilizing autologous fat
and liposuction techniques. Plast Reconstr Surg. 1987;79:267.
3. Delay E.Lipomodeling of the reconstructed breast. In: Surgery of
the breast: principles and art; 2012.
4. Khouri RK, Khoari RK, Rigotti G, Marchi A, Cardoso E, Rotemberg
SC, etal. Aesthetic applications of Brava-assisted megavolume fat
grafting to the breasts: a 9-year, 476-patient, multicenter experience. Plast Reconstr Surg. 2014;133:796.
5. Al Sufyani MA, Al Hargan AH, Al Shammari NA, Al Sufyani
MA. Autologous fat transfer for breast augmentation: a review.
Dermatol Surg. 2016;42:1235.
6. Coleman SR, Saboeiro AP. Primary breast augmentation with fat
grafting. Clin Plast Surg. 2015;42:301.
7. Simonacci F, Bertozzi N, Grieco MP, Grignafni E, Raposio
E.Procedure, applications, and outcomes of autologous fat grafting. Ann Med Surg. 2017;20:49.
8. Voglimacci M, Garrido I, Mojallal A, Vaysse C, Bertheuil N, Michot
A, etal. Autologous fat grafting for cosmetic breast augmentation:
a systematic review. Aesthet Surg J. 2015;35:378.
9. Niechajev I, Śevćuk O. Long-term results of fat transplantation.
Plast Reconstr Surg. 1994;94:496.
10. Rohrich RJ, Sorokin ES, Brown SA. In search of improved fat
transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg. 2004;114:1945.
11. Del Vecchio DA, Bucky LP.Breast augmentation using preexpansion and autologous fat transplantation: a clinical radiographic
study. Plast Reconstr Surg. 2011;127:2441.
12. Oranges CM, Striebel J, Tremp M, Madduri S, Kalbermatten DF,
Schaefer DJ. The impact of recipient site external expansion in
fat grafting surgical outcomes. Plast Reconstr Surg Glob Open.
2018;6:e1649.
13. Liu W, Luan J.Recent advances on the application of negative pressure external volume expansion in breast plastic surgery. Aesthet
Plast Surg. 2018;42:112.
14. Abboud MH, Dibo SA, Abboud NM.Power-assisted liposuction
and lipolling: techniques and experience in large-volume fat grafting. Aesthet Surg J. 2020;40:180.
15. Mangialardi ML, Ozil C, Lepage C. Cosmetic breast augmentation using power-assisted liposuction and lipolling: a prospective
study. Aesthet Plast Surg. 2021;45:1975.
16. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited:
safety and efcacy. Plast Reconstr Surg. 2007;119:775.
17. Rosing JH, Wong G, Wong MS, Sahar D, Stevenson TR, Pu
LLQ.Autologous fat grafting for primary breast augmentation: a
systematic review. Aesthet Plast Surg. 2011;35:882.
18. Zheng DN, Li QF, Lei H, Zheng SW, Xie YZ, Xu QH, et al.
Autologous fat grafting to the breast for cosmetic enhancement:
experience in 66 patients with long-term follow up. J Plast Reconstr
Aesthet Surg. 2008;61:792.
19. Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring.
Aesthet Plast Surg. 2008;32:313.
20. Kontoes P, Gounnaris G. Complications of fat transfer for breast
augmentation. Aesthet Plast Surg. 2017;41:1078.
21. Groen JW, Negenborn VL, Twisk JWR, Ket JCF, Mullender MG,
Smit JM. Autologous fat grafting in cosmetic breast augmentation: a systematic review on radiological safety, complications,
volume retention, and patient/surgeon satisfaction. Aesthet Surg J.
2016;36:993.
Breast Fat Augmentation. Step-by-Step
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Technique andUltrasound Assisted
24
Liposuction for Contouring ofDonor
Area
AlbertoDi Giuseppe andFedericoGiovagnoli
Contents
24.1 Introduction 325
24.2 Step by Step 331
24.3 Breast Planning and Body Planning 331
24.4 Advantages of Fat Grafting 332
24.5 Breast Cancer Detection 333
24.6 Technique 333
24.7 Operative Technique 334
24.8 Post-op Care 340
24.9 Clinical Cases 347
References 353
24.1 Introduction
In 2009, Panetta etal. [1] published on Plastic Reconstructive
Surgery Journal a paper on the effects on the third generation
ultrasound liposuction (VASER) on adipose tissue. The
paper analyzed the fact of ultrasound energy delivered by
VASER and then suctioned through the VentX system on the
lipoaspirate for autologous fat transfer (AFT) as a source
material for adipose-derived regenerative cells (ADRCs),
already known as stem cells. Panetta analyzed the viability
of adipose tissue (fat cell) obtaining data which shows that
the fat lipoaspirated from VASER ultrasound device contains
viable fat cells as well as standard liposuction. In this study,
he found also a mixture of cell types within the ADRCs
obtained from the adipose tissue. New guidelines were suggested to make the utilization of the VASER ultrasound system and the VentX aspiration system for body contouring
procedures more effective (Fig.24.1).
A. Di Giuseppe (*)
University of Padova, Padova, Italy
F. Giovagnoli
University Vita-Salute San Raffaele, Milan, Italy
Adipocyte viability of unprocessed samples ranges
between 85.1±11%.
VASER aspirate adds aqueous content of 20.7 ±2% in
free lipids content of 5.29±1.8%.
After processing in the pure graft system, aqueous, and
free lipids are reduced to 16.5±3.5% and 0.63±0.5%.
After processing in the Celution System by Cytori, the
mean viability of ADRCs cells was found to be 87.4±4.58%.
Post freezing viability of ADRCs dropped to 11%, after
cryo preservation 50%.
A standard VASER treatment followed by low-vacuum
aspiration using the VentX system, achieved as raw fat viability of 85%.
Also, by maintaining the overall cell population of the
lipoaspirate (mature adipocytes and the “loosely adherent”
cell population: peri-adipocytes, stem cells, stromal cells,
etc.), the success rate of the implanted tissue matrix is
enhanced.
In addition to the use of harvested fat for immediate reinjection, adipose tissue is a signicant source of stem cells for
both enhancement of autologous fat grafts and for use in
other developing clinical treatments.
As with direct autologous fat injections, the viability of
the regenerative cells derived from the harvested adipose tis-
© 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_24
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Fig. 24.1 The two diagrams show the adipocyte viability and the ADRC viability using VASER ultrasound liposuction. Results are similar to fat
removed from standard liposuction
A. Di Giuseppe and F. Giovagnoli
sue is of primary importance, both as fresh tissue and after
freezing.
The eld of clinical treatments using adult stem cells continues to expand and patients undergoing liposuction are
increasingly interested in storing tissue samples containing
stem cells.
These cells could then be tawed at some future date and
utilized in the development of genetic- and tissue-based
treatments.
The viability of the adipose-derived stem cells was higher
than that for the overall tissue samples and over 87%.
More importantly, the viability of the adipose-derived
stem cells was only slightly reduced to 75% after freezing
using liquid nitrogen vapor.
In this application, the separation of the cells using the
VASER System minimized tissue damage and improves the
viability of the harvested cells.
The VASER Ultrasound system and the VentX Aspiration
System provide an efcient means of harvesting adipose tissue without sacricing tissue viability.
Guidelines includes:
1. Donor area: abdomen, anks, and thighs
2. Tumescent inltration of uid: 2mL inltrated for every
1mL removed
3. VASER performed with 3.7mL probe at an amplitude of
60% in pulsed VASER mode
4. Aspiration occurred using VentX cannula diameter of
3.0mm at a vacuum level of 15in hg
In my clinical experience, I have followed those guidelines in my rst 180 cases of breast fat augmentation using
VASER liposuction from 2010 to 2013.
In August 2013, a letter was published on Plastic
Reconstructive Surgery Journal written by Severiano Vilaboa
and Ramon Llull (Stem center of Palma de Mayorca, Spain)
[2]. They summarized the variables that make unpredictable
the post-surgical volume loss, in AFT.Among those, lack of
adequate vascularization, lack of regenerative cell within the
fat graft, the traumatic handling of the fat during preparation
and implantation, immunosystem-mediated cellular phagocytosis in the proinammatory environment after grafting, or
likely a combination of all of these effects.
They advocated returning fat graft to physiologic condition using washing: in other words, the long-term survival
rate of the harvested fat was deeply connected also to the
restoring of the physiologic condition of fat, which was too
aqueous with previous technique utilized.
When I started performing fat extraction, I utilized as the
Puregraft™ System, as the Acquavage system [3, 4]. Both
the systems had the advantage to obtain a liquid fat, easy to
be injected (Fig.24.2).
The aqueous liquid content of grafts prepared using the
different preparation methods can be seen for one representative sample. The numerical data of all samples were presented as average percentage of the total graft. Compared to
unmanipulated control samples (33.21±1.8%) and the samples prepared by gravity separation (24.5±1.4%), the graft
tissues prepared by centrifugation and Puregraft contained
signicantly less liquid (p<0.001 for all comparisons). The
mean liquid content of tissue prepared using Puregraft was
8.1±0.9%, which was comparable to that of graft tissue prepared by centrifugation (5.2±0.5%). In addition, the uid
content in grafts prepared by the Puregraft system may be
adjusted to a wider range (from 2.67% to 20%), depending
on the drain time and drain techniques (active or passive)
used. Thus, physicians can control the graft viscosity to their
desired consistency.
But as contra, swelling post surgery was impressive, and
absorption or retention of real fat was about 60% of the total
24 Breast Fat Augmentation. Step-by-Step Technique andUltrasound Assisted Liposuction for Contouring ofDonor Area
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Fig. 24.2 Puregraft™ System—Acquavage system for fat harvesting and collection. Note the aqueous prevalence of the harvested fat
327
infused, in my clinical experience. As you can see in this
clinical example of breast augmentation using Puregraft system, the swelling of the rst post-op day is really impressive
(Fig.24.3b): but in 10–20days, the edema is absorbed and
nal volume reached is much less that desired and expected.
This could lead to dissatisfaction of both patient and surgeon
in terms of expectations of achievable volume. Sometimes
patient commented that part of the fat had already been
absorbed, or the technique was wrong [5].
In order to reduce the aqueous component of harvested
fat, a new system called REVOLVE™ (Allergan) was introduced on the market, and I have started to utilized in all
major procedures of a fat harvesting and transfer performed
in the past decade.
REVOLVE™ System (Fig. 24.4) 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.
The adipose tissue after sampling has little physiological
conditions that enhance its fragility.
The increase in LDH and triglycerides (TGC) retard
angiogenesis and engraftment fat.
The rapid return to plasma osmolarity (270–300mOsm/L)
through the wash shows the adipose tissue to the initial conditions with a physiological pH, osmolarity in the standard,
removing hemoglobin, erythrocytes, and triglycerides.
This diagram shows the comparison among the contents
of triglycerides (above, left), the release of lactate dehydrogenase (above, right), the hematocrit (below, left), and the
osmolarity (below, right) in adipose tissue decanted compared to washed adipose tissue by the device REVOLVE™
(Fig.24.5).
The grains contain fat for replanting adipose tissue and a
variable amount of water.
1. A high percentage of water makes the graft semi-liquid
and easy to inject, but entails a loss of important secondary volume.
2. A low percentage of water determines a graft too often to
inltrate and requires an excess pressure in the cannula
and into the tissues (Fig.24.6).
The percentage of water adipose graft should be between
10% and 20% to allow for easy installation and a minimal
loss of volume.
1. A syringe of lipoaspirate, after 15/20 min still contains
20–30% of water content (longer than settling
down=water).
2. A system of uid lter or a centrifuge can be used to
improve this result (Fig.24.7).
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
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A. Di Giuseppe and F. Giovagnoli
Fig. 24.3 (a–d) Breast augmentation with Puregraft™ System. Note massive swelling of breast 1day after surgery (360mL infused for side).
Note at day 10, swelling is reduced and denitely absorbed at day 21
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 integrated, high-volume fat processing system
designed by adipose transplantation pioneers and founders
of the International Federation for Adipose Therapeutics and
Science.
REVOLVE™ System is an autologous fat tissue [AFT]
collection device and tissue delivery system and collects
autologous adipose tissue and rapidly washes and delivers
the tissue for body contouring.
It 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
Fig. 24.4 The REVOLVE™ System. (Courtesy LifeCell Corporation,
an AbbVie company. ©2021 AbbVie. All rights reserved [6])
emptied a second time during the same surgery on the same
patient.
TGC Content (oil)
Hct (%)
Decanted
LDH Release
24 Breast Fat Augmentation. Step-by-Step Technique andUltrasound Assisted Liposuction for Contouring ofDonor Area
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Fig. 24.5 Comparison of the
contents [7]. (Courtesy
LifeCell Corporation, an
AbbVie company. ©2021
AbbVie. All rights reserved
[6])
1.5
1.0
0.5
TGC (g/L)
4000
3000
2000
LDH (U/L)
1000
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0.0
Decanted Tissue Sample
2.5
2.0
1.5
1.0
0.5
0.0
Tissue Sample
GID Washed Adipose
GID Washed Adipose
0
Decanted Tissue Sample
OsmolarityHematocrit
350
300
250
mOsm/L
200
Decanted Tissue Sample
GID Washed Adipose
GID Washed Adipose
Fig. 24.6 Fat in the REVOLVE™ dispositive before and after washing
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