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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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Fig. 24.7 Design of the fan. (Courtesy LifeCell Corporation, an
AbbVie company. ©2021 AbbVie. All rights reserved [6])
A. Di Giuseppe and F. Giovagnoli
requiring fewer steps to process large quantities of adipose
tissue and it is less time consuming than other competitive
devices.
All-in-one integrated device: harvests, processes, and
extracts lipoaspirate within one canister. Quickly processes
fat, it lters during harvesting and actively washes and separates collagen strands. It is an integrated system that allows
loading of syringes for injection directly from canister.
Processes a large volume of lipoaspirate with fewer steps
compared to LipoVage® and Puregraft™ device. It is a timeefcient system that minimizes training, preparation, and
clean up time, requiring only one operator, can be placed on
the sterile eld, and can be used multiple times for the same
patient within the same procedure.
In a preclinical study, human fat injected into animals was
processed using three different methods:
It is a decant method and centrifuge method (processed at
1200g for 3min).
Yielded a higher concentration of adipose tissue with signicantly less debris and oil.
The system minimized potential inammatory response
for transplanted tissue by signicantly removing red blood
cells, fatty acids, and debris and obtaining yielded more predictable results.
Based on the preclinical study, it yielded signicantly
higher fat graft retention than decantation and similar to
centrifugation.
REVOLVE™ System processed a higher percentage of
adipose tissue compared with the two other methods: decantation and centrifugation [7, 8].
Fig. 24.8 Strands of collagen after washing
The propeller for active washing enhances the washing
process for high-quality fat, removes collagen strands to
minimize injection syringe clogging (Fig.24.8), and allows
direct load of syringes for injection from canister to minimize steps and extraction with catheter tip or Luer-Lock
syringe.
The mesh lter is designed to lter and strain lipoaspirate
during the harvesting phase and active mechanical washing
process and rapidly removes tumescent, reduces cell debris,
eliminates free oil, and concentrates adipose tissue.
The REVOLVE™ System can processes up to 700mL
of lipoaspirate in less than 10min and it is easier to use,
1. Yielded signicantly less blood cell debris and a lower
percentage of free oil.
2. Signicantly higher fat graft retention (73.2%) than decantation (37.5%) and similar to centrifugation (67.7%).
3. Maintained fat in physiological conditions (pH and
osmolarity).
4. The study included 37 patients over a 6 months period,
including 13 Coleman technique patients, and 24
REVOLVE™ System patients.
5. The average rate of fat transfer was 1.77 cc/min for
Coleman and 4.69 cc/min for REVOLVE™ System,
which was a statistically signicant difference between
groups.
6. The study included a total of 118 patients in the centrifugation and 103 patients in the REVOLVE™ System
group.
7. REVOLVE™ System processed more fat per minute than
centrifugation, decreasing operating time and possibly
OR costs.
24 Breast Fat Augmentation. Step-by-Step Technique andUltrasound Assisted Liposuction for Contouring ofDonor Area
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24.2 Step by Step
Patient candidate for breast fat augmentation:
1. Adequate fat donor areas
2. Realistic expectations for volume enhancement (1–2
sizes)
3. Natural results expected
4. Highly motivated patients with full understanding of pro
and contra of the procedures
5. Patients with pathologies of breast to be excluded (ultrasound before surgery required)
6. Patient with high oncologic risk to be excluded
7. Patient needs to maintain weight in order to retain the
transferred fat
8. Gym and diet could consistently decrease the amount of
fat transferred (as in all diet)
24.3 Breast Planning andBody Planning
Planning of breast includes traditional measurements as distance from mid-clavicle to nipple, from nipple to inframammary fold, and from nipple to midline. Breast is
commonly divided into four quadrants (Fig.24.9).
For body contouring, I mark the outline of the areas to be
considered for fat removal. Markings are in front, posterior,
and both lateral projection (Fig.24.10). I mark the outer contour of the fat excess, the lines of transition between areas. I
mark in the red line the areas not to be touch. I try to draw
lines of concavity and convexity in order to recreate a good
shape and proportion with the body. With experience, a plastic surgeon can predict the amount of fat he will be able to
collect in a patient, with a good approximation. I normally
guess that I will succeed increasing 1 cup size breast by
using 200 mL of harvested fat (400 mL for each side to
Fig. 24.9 Breast planning and measurements divided in four quadrants
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A. Di Giuseppe and F. Giovagnoli
Fig. 24.10 Planning and
marking body areas: in blue
areas of fat removal, in red
forbidden areas. Vertical blue
lines: top line of prominence
1: Flanks
2: Pre-sacral triangle
3: Upper buttock definition
4: Red forbidden area
5: trochanter prominence
6: new buttock crease
7: Banana fold
1: Anterior flank
2: red forbidden f
3: Vertical blue antero-lateral
thigh
4: Oblique blue inner side of
thigh
5: Knee
Fig. 24.11 Favorite incision
lines of breast (submammary
mostly preferred)
obtain a 2 cup size increase). Minding that the inltration
rate is normally twice than aspiration, I plan 2500 mL of
aspirate (with 5000mL inltration to obtain around 1600–
1800 of pure fat to be inltrated), counting loss of debris of
solution, blood, triglyceride, and oil (Fig.24.11).
24.4 Advantages ofFat Grafting
No implant leakage, or deation
No capsule contracture
No palpability
24 Breast Fat Augmentation. Step-by-Step Technique andUltrasound Assisted Liposuction for Contouring ofDonor Area
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No visibility
Natural appearance
Natural feeling
24.5 Breast Cancer Detection
Calcications and fat necrosis occur with every type of
breast surgery: breast biopsy, implant procedure, radiation
therapy, breast reconstruction, breast reduction, and liposuction of the breast.
Incidence rate of calcication can be as high as 50% of
patients after 2years.
Radiologists knows how to distinguish calcication of
malignant causes from the benign calcication from fat
necrosis.
Bircol [9] reported 1.4% of incidence rate of
microcalcication.
Fat placed even in small aliquots can necrose and develop
small fat cysts and calcications.
Post-op follow-up with ultrasound scan or mammograms
are recommended at 1year and regular interval.
3D imaging helps long-term evaluation of fat survival.
Breast cancer detection remains the safety issue, not the
incidence of calcications.
I routinely ask to perform an ultrasound scan to any
patient before undergoing fat transfer to breast. This simple
investigation will allow to detect minor lumps or any suspicious pathology of breast. Mammograms of RMI are
requested only in more complicated patients, as initial investigation. I frequently ask a second oncological opinion in
challenging cases, and I refuse patient with strong hereditary
history of family breast cancer.
24.6 Technique
1. Selection of patient candidate for fat transfer to breast
Fair amount of fat to be transferred to breast.
Realistic expectation of patient (1–2 breast size
increase, no spectacular projection achievable).
Good initial position of nipple (18–22 cm from
midclavicle).
Patient must give privilege to natural results achiev-
able more than to the volume and projection.
For this purpose, I do show patients a prospective
achievable result using 3D imaging system (CRISALIX)
(Fig.24.12).
2. Selection of sites of fat harvesting
Abdomen, anks, thighs, knees, upper arm, back,
trunk.
3. Selection of technique of fat removal
Liposuction, VASER ultrasound assisted, laser
lipolysis.
4. Selection of anesthesia
Modied local tumescent plus IV sedation.
Intercostal nerve blocks (high epidural).
General anesthesia (Fig.24.13).
In my experience, in close breast fat enhancement, I inltrated fat into different levels by layering in order to better
shape and dene breast cone. The principle is to graft selectively from the chest wall to the skin, placing fat under the
glandular tissue and subcutaneously. Skin incision is 1.5cm
large, and I normally start with midline inframammary
incision.
Fig. 24.12 3D imaging simulation
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a b
Fig. 24.13 (a) Level of fat inltration. Subglandular and subcutaneous. (b) Special cytori 10mL syringes
24.7 Operative Technique
A. Di Giuseppe and F. Giovagnoli
Once the fat is emulsied with VASER liposuction, it is aspirated and collected in the REVOLVE canister. It could collect up to 350mL of emulsied fat, which is then added with
250mL of ringer lactate solution, prewarmed at a temperature of about 38°C to optimize washing (Fig.24.14).
The washing procedure is repeated three times alternating
with the spinning to help separation and decanting of the
emulsied washing fat. It is possible to collect up to 1000mL
of emulsied fat throughout three times aspirating and washing the emulsied fat. After processing the fat (washing,
spinning, and decanting), it is possible to obtain a good quality of “grain fat” (Fig.24.15).
Once fat is washed and spinned, the nurse or assistant
will start the aspiration from REVOLVE canister by using
60 mL Luer-Lock syringes until the canister is empty.
Syringes are collected on the rack and left them to decant
(Fig.24.16a, b).
Fat is then transferred from 60 mL syringes to 10 mL
syringes to continue cleaning of fat, with minimal pressure,
through a connector (Figs.24.17 and 24.18).
Once the nurse has completed the processing of fat in the
different areas (anks, trunk, abdomen, thighs, etc.), the surgeon must concentrate on the sculpturing of the body areas
which have gone under treatment.
Achieving a good symmetry and a nice contour is a must
of the surgeon: the procedure is an association of removing
fat from stubborn areas and sculpturing and recreating concavity and convexity lines of the natural ideal body shape.
Supercial VASER liposuction helps contouring body and
Fig. 24.14 REVOLVE canister lled with fat and then washed
recreating nice lines, but talent of surgeon and ability in
sculpturing the “body material” are essential for achieving a
nice contouring result (Figs.24.19 and 24.20).
Breast fat transfer utilizes 10 mL syringes with 2.7–
3.0mm cannula: this is the optimal compromise to lower the
pressure of the syringe through the fat and thus diminishing
damages to harvested fat. Also the utilization of a one hole
3.0mm cannula is ideal, minding the “grain” structure and
dimension of the harvested fat without the aqueous component. Less aqueous is the grain fat to transfer, larger has to be
the cannula to be used. With the previous Acquavage system,
fat transferred was more aqueous and easy to be injected
with smaller cannulas, but the swelling was major and fat
absorption more substantial (Fig.24.21).
The lling process starts with a submammary 2–3 mm
skin incision and progresses from the upper quadrants in
24 Breast Fat Augmentation. Step-by-Step Technique andUltrasound Assisted Liposuction for Contouring ofDonor Area
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Fig. 24.15 Grain fat after processing with the REVOLVE canister. Note the consistency of fat and the little aqueous component
Fig. 24.16 (a) 60mL
Luer-Lock syringe to aspirate
from REVOLVE canister. (b)
Syringes collected on the rack
and left for decanting
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Fig. 24.17 Fat transfer from a 60mL syringe to a 10mL syringe
order to ll emptiness of the top breasts. With two experienced surgeons, the lling must be bilateral at the same time
in order to speed up the process. A good coordination and a
teamwork is essential to progress symmetrically and achieve
a good aesthetic contouring. Nurse must record the total of
fat available and give similar amount of fat to be lled side to
side and quadrant to quadrant (upper, lower, internal, and
external) (Fig.24.22).
Fig. 24.18 60mL syringes of fat ready for harvesting
In order to achieve an increase of nipple and breast projection, fat lling must be concentrated on the lower and
medial quadrants.
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Fig. 24.19 Immediate post-op result after VASER contouring of anks, trunk, outer thighs, adding also fat to better contouring and project at
buttocks
Fig. 24.20 Pre- and post-op
comparison
A. Di Giuseppe and F. Giovagnoli
Upper pole fat transfer is performed after lower poles are
already enhanced; this depends on the total fat available and
the ideal volume distribution.
Artistry of surgeon plays an important role: sense of
beauty and proportions are needed to progressively achieve
nice sculptured breasts (Fig.24.23).
Breast cleavage is one of the best targets and desires of
women worldwide in breast aesthetic surgery. In order to
improve cleavage, fat lling of the medial quadrant is
essential. Surgeon must continuously check with his contralateral hand the proper positioning of the fat
(Fig.24.24).
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Fig. 24.21 3mm one hole cannula
Fig. 24.22 Simultaneous bilateral breast fat augmentation, lling upper and lower quadrants as by original drawings
Filling the retro areolar space, always in a subglandular
layer, is the next step to increase breast shaping in my own
sequence. I normally use last syringes of fat to add those areas,
after a good shape has been already achieved (Fig.24.25).
Breast fat augmentation has a similar target than augmentation with implant: recreating a nice breast cone, with
improved volume and projection and natural shape. In order
to achieve those goals, surgeon must have precise ideas of
body proportions and the desired shape. His talent and sense
Fig. 24.23 Filling lower medial quadrants to increase breast
projection
of proportion and beauty is essential in order to achieve a
good aesthetic result (Figs.24.26, 24.27, and 24.28).
A second incision at the sternum is sometime necessary to
better ll the medial quadrant and improve breast cleavage.
A nal assessment must include: symmetry of breast
shape and volume, contouring of body anks in harmony
with increase breast shape. Post-op assessment is done
through proper visualization from lower, lateral, and top
breast position.
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Fig. 24.24 Breast cleavage: lling medial breast quadrant
A. Di Giuseppe and F. Giovagnoli
Fig. 24.26 Achieving a nice
breast cone and body
concavity and convexity lines
Fig. 24.25 Last step: retro areolar space lling
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Fig. 24.27 Second incision in the sternum to complete medial quadrant lling
Fig. 24.28 Final assessment
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