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N. Zingaretti et al.
Overall, implants and fat, working together, provide the
best attributes each has to offer: the core volume projection
of implants and the natural look and feel of fat.
As seen by Maximiliano et al. [32], hybrid breast augmentation technique may be limited by the volume of autologous fat that can be grafted, since there is an inverse
relationship between the autologous fat graft volume and fat
integration.
26.3 Breast Implants andFat
As described by Bach etal., implants have been proposed as
solution when autologous reconstructions failed to give a
satisfactory result in terms of symmetry, shape, and projection [29]. But if the relationship between implants and autologous aps has been largely studied, the relationship between
them and fat graft is already under investigation.
Total breast reconstruction with fat only is desirable, but
not reachable at the moment. The use of implants will continue to be necessary unless new technologies are discovered
to stabilize the shape of full-fat reconstructed breasts, achieving better fat survival through fat enhancement techniques or
through dedicated scaffolds to drive cell regeneration and
shape denition [15].
The development of fat-injection techniques to rene the
results of implant-based breast reconstructions or breast augmentation is changing the outcomes of breast surgery [15].
The advantages of fat grafting in implant-based reconstruction or breast augmentation are well described.
Papadopoulos etal. observed better breast sensation, reduced
foreign body sensation, reduced tension after radiotherapy,
and reduced feeling of cold breast in patients treated with fat
grafting. They also reported fat grafting can be used for pain
relief due to capsular formation, regardless of the implant
position to the pectoral muscle [33]. Roca etal. rst evaluated the efcacy of autologous fat grafting in a porcine model
as a treatment for capsular contracture [34]. Moreover, they
conrmed that fat grafting, due to its regenerative properties,
can ameliorate brotic damage in particular in implant-based
reconstruction and successive radiation therapy. These
results conrmed the trend of the past decade, when radiotherapy damage has been treated with autologous fat cell
transplantation [35].
What implant has to be used with fat grafting is a debated
argument. Maximiliano et al. obtained the ideal shape for
hybrid breast augmentation using round implants and adding
fat graft in a pattern similar to a cone shape on the upper portion of the implant [20]. In this way, they could calculate the
accurate fat volume required for each of the three different
implant projections. For example, for moderate prole
implants, which have a proportionally larger base diameter,
larger fat volumes were expected.
The evolution of silicone implants led to the introduction
of new surfaces and viscoelastic gel properties. Smooth and
micro/nanotextured implants were created with the aim to
have very low roughness to avoid tissue ingrowth, minimize
bacteria adhesion, and nally have the best natural aspect.
Another reason strongly moved this evolution. During the
past years, a new dened form of neoplasm, called BIAALCL, has been introduced. This rare form of lymphoma
has been seen associated with macrotextured breast implants,
but the physiopathology is still not completely clear to date.
Chronic inammation generated by these types of implants
(probably caused by biolm born on textured surface) is the
main cause investigated [36, 37]. For this reason, smooth
implants have been now re-evaluated, macrotextured
implants have been removed in a lot of countries, and micro/
nanotextured implants have been strongly developed as alternatives to smooth ones.
Breast augmentation recently had signicant progress in
aesthetic outcomes after the introduction of new-generation
silicone gel implants and advances in fat grafting. Most surgeons associate fat grafting in the upper, medial and lateral
areas of the breast, where thin tissue provides insufcient
coverage and leads to implant visibility.
Fat grafting technique is a substantially safe procedure,
but the result is unpredictable, with long-term retention rates
varying between 10% and 80% [38].
If major complications occur in the rst postoperative
weeks, minor complications occur up to 6 months after
surgery. The most common complication of fat grafting is
fat necrosis, which can hesitate in oil cyst formation and
calcications. Palpable masses can develop due to fat
necrosis.
The formation of cystic lesions, with the consequent functional and aesthetic manifestations to the patient, is mostly
probably related to the massive transfer of fat clumps in the
breast tissue, which led to fat necrosis and encapsulation
[39]. Fat transplantation in the breast parenchyma might be
another reason for this complication. Maintaining the viability of the harvested fat cells is crucial. The chances of survival are higher the less the fat graft is manipulated and the
more quickly it is reinjected.
Ørholt etal. described an overall 2.1% of complications
after hybrid breast augmentation [40]. In particular, they
observed 1.6% of major complications (as seroma, hematoma, and infection) and 0.5% of minor complications (palpable cysts), but none of the patients underwent surgical
revision.
26 Hybrid Fat Transfer, Breast Implants, andFat
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373
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Bourkoula E, Manini I, Bergamin N, Toffoletto B, Beltrami CA,
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13. Serra-Renom JM, Munoz-Olmo JL, Serra-Mestre JM.Fat grafting
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CA, Rubin JP. Trends in autologous fat grafting to the breast: a
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30. Auclair E, Blondeel P, Del Vecchio DA.Composite breast augmentation: soft-tissue planning using implants and fat. Plast Reconstr
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32. Maximiliano J, Munhoz AM, Pedron M, de Oliveira ACP, Duarte
DW, Neto R, Portinho CP, Collares MVM.Hybrid breast augmentation: a reliable formula for preoperative assessment of fat graft
volume based on implant volume and projection. Aesthet Surg J.
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33. Papadopoulos S, Vidovic G, Neid M, Abdallah A.Using fat grafting to treat breast implant capsular contracture. Plast Reconstr Surg
Glob Open. 2018;6:e1969.
34. Roca GB, Graf R, da Silva Freitas R, Salles G Jr, Francisco JC,
Noronha L, Maluf I Jr. Autologous fat grafting for treatment of
breast implant capsular contracture: a study in pigs. Aesthet Surg
J. 2014;34(5):769–75.
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2018;45:4–13.
36. Cordeiro PG, Ghione P, Ni A, Hu Q, Ganesan N, Galasso N, Dogan
A, Horwitz SM.Risk of breast implant associated anaplastic large
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37. Zingaretti N, Vittorini P, Savino V, etal. Surgical treatment of capsular contracture (CC): literature review and outcomes utilizing in
revisionary surgery. Aesthetic Plast Surg. 2021;45:2036–47. https://
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38. Simonacci F, Bertozzi N, Pio Grieco M, Grignafni E, Raposio
E.Procedure, applications, and outcomes of autologous fat grafting. Ann Med Surg (Lond). 2017;20:49–60.
39. Kontoes P, Gounnaris G. Complications of fat transfer for breast
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40. Ørholt M, Larsen A, Hemmingsen MH, Mirian C, Zocchi ML,
Vester-Glowinski PV, Herly M.Complications after breast augmentation with fat grafting: a systematic review. Plast Reconstr Surg.
2020;145(3):530e–7e.
Percutaneous Fasciotomy andFat
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Grafting fortheCorrection
27
oftheTuberous Breast Deformity
PatriciaGutierrez-Ontalvilla andNinaS.Naidu
Contents
27.1 Introduction 375
27.2 Etiology 376
27.3 Epidemiology 376
27.4 Histopathology 376
27.5 Classication 376
27.6 History of Correction 377
27.7 Percutaneous Fasciotomy and Fat Grafting for the Correction of the Tuberous Breast
Deformity 377
27.8 Prognosis/Results 379
27.9 Complications 382
27.10 Conclusions 382
References 383
27.1 Introduction
Tuberous breast deformity was rst described by Rees and
Aston in 1976 as a congenital malformation due to abnormal
mammary development that becomes evident at puberty.
This deformity results in a tubular shape of the breast resulting in hypoplasia of the lower quadrants, an elevated inframammary fold, herniation of the nipple–areola complex, and
an increased areola diameter [1] (Fig.27.1). This malformation frequently causes anxiety, lack of self-condence, and
P. Gutierrez-Ontalvilla
Hospital La Fe, Unit of Plastic Surgery, Valencia, Spain
e-mail: patricia@dragutierrez.com
N. S. Naidu (*)
Weill Cornell Medical Center, New York, NY, USA
e-mail: drnaidu@naiduplasticsurgery.com
© 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_27
isolation in teenagers [2]. The traditional solutions for correction have included breast remodeling techniques and the
use of implants. However, correction of the tuberous breast
with implants carries specic complications including asymmetry, implant displacement, rippling, capsular contracture,
late seromas, and potential nancial costs due to implant
replacement [3]. Since Coleman’s original description of
lipostructure [4], we have implemented fat grafting as an
option in the correction of tuberous breasts as it provides
optimal results without the need for implants or aps.
375
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Fig. 27.1 Anatomy of the
normal and tuberous breasts
P. Gutierrez-Ontalvilla and N. S. Naidu
27.2 Etiology
The pathology of the tuberous breast is generally congenital
and has an unknown etiopathogenesis. There is a possible
genetic role in the development of the tuberous breast deformity, with a possibility of parental consanguinity for such
breast deformities [5]. Grolleau etal. have proposed a cause
secondary to anomalies of the fascia supercialis, which
involve strong adherence between the dermis and the muscular plane, restricting peripheral expansion of the breast during development at puberty [6].
27.3 Epidemiology
The exact incidence of the tuberous breast is unknown and
would likely be difcult to quantitate due to the large number
of women with mild deformity who may be unaware of their
diagnosis. One retrospective analysis revealed a high prevalence of tuberous breast deformity in the general population
(approximately 50%), and in particular in women requesting
breast surgery [7].
27.4 Histopathology
in both placement and quantity. These bers sometimes
appear to be assembled in bundles, contributing to the typical glandular rmness, fascial thickening, and general
brosis [8].
27.5 Classication
The tuberous breast has different degrees of severity, and it is
mandatory that the surgeon understand these varieties. By
identifying the degree of deformity, the surgeon can design
and perform the optimal surgical treatment for each patient.
There are two predominant classication systems within
the literature.
27.5.1 Von Heimburg Classication [9]
Type I: Hypoplasia of the lower medial quadrant
Type II: Hypoplasia of the lower medial and lateral
quadrants
Type III: Hypoplasia of the lower medial and lateral quad-
rants with deciency of the skin in the subareolar region
Type IV: Severe breast constriction with minimal breast
base
Tuberous breast deformity is marked not only by thickening of the fascia supercialis but also brosis of the breast
parenchyma brosis. The underlying pathogenesis includes
signicant differences in quantity and disposition of collagen bers in patients with tuberous breasts as compared to
normal breasts. Indeed, collagen bers appear to be altered
27.5.2 Grolleau Classication [6]
Type I: Hypoplasia of the lower medial quadrant
Type II: Hypoplasia of both lower quadrants
Type III: Hypoplasia of all four quadrants
27 Percutaneous Fasciotomy andFat Grafting fortheCorrection oftheTuberous Breast Deformity
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27.6 History ofCorrection
Many surgical techniques have been proposed for correction
of the tuberous breast deformity. Rees and Aston initially
described radial incisions in the breast parenchyma for release
of the constrictive bands with reduction of the nipple–areolar
complex and placement of subglandular implants [10].
Ribeiro et al. have described a technique that uses an
exclusively periareolar approach to divide the breast into two
portions to disrupt the constricting ring and create an inferiorly based pedicle [11]. Mandrekas etal. proposed a similar
approach, with a periareolar incision and transection of the
constricting ring. Two vertical breast pillars are formed and
folded together to provide volume to the lower pole of the
breast [12].
The use of combined periareolar and inframammary incisions associated with breast implants was described by
Teimourian and Adham [13]. Most patients with tubular
breasts desire an increase in breast volume and improvement
in shape, both of which are provided by this technique.
The current chapter presents a procedure for the correction of tuberous breasts with the use of percutaneous fasciotomies and fat grafting with areolar reduction [14]. This
approach permits correction without the use of aps and
implants that might mandate future revision surgery.
27.7 Percutaneous Fasciotomy andFat
Fig. 27.2 Drawing representing planning for autologous fat grafting.
Each breast is divided into quadrants and the cannula entry ports
(located at the new inframammary fold, anterior axillary line, and the
intersection of the upper quadrants) are designated. Introduction of the
cannula through the areola is avoided so as to avoid harm to the glandular tissue
Grafting fortheCorrection
oftheTuberous Breast Deformity
377
Prior to surgery, the breasts are marked with the patient in the
standing position. Each breast is divided into four quadrants
according to the method of Silva-Vergara to better assess the
areas of deciency and thus to estimate the quantity of fat to
be injected (Fig.27.2) [15].
The new inframammary fold is marked at a lower and
more anatomic position. A circumareolar skin reduction is
marked in all cases to allow for the reduction of the herniated
tissue and to reduce the areolar diameter. The fat donor sites
used are typically the abdomen, trochanteric zones, and inner
thighs, although this varies depending upon both the individual patient’s fat distribution and where the surgeon can
most easily access the donor sites.
All surgical procedures are performed under general
anesthesia. The nipple–areolar complex and areolar herniation are rst reduced with the use of 38-mm marker to delineate the new areolar margin. The circumareolar incision is
then closed in layers with 3-0 PDS sutures for the subcutaneous tissue, CV-3 Gore-Tex suture (Gore-Tex, W.L.Gore and
Associates, Flagstaff, AZ, USA) placed in an interlocking
round-block pattern to reduce the areolar diameter and a running 4-0 PDS for the cuticular margin (Figs.27.3, 27.4, and
27.5). The fat donor sites are then inltrated with saline solu-
Fig. 27.3 Marked reduction of the nipple–areolar complex
tion containing epinephrine but without lidocaine (1000cc
saline solution with 1cc epinephrine) in a 1:1 proportion to
the amount of fat to be harvested.
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Fig. 27.4 Dermal closure of the reduced areola
P. Gutierrez-Ontalvilla and N. S. Naidu
Fig. 27.5 Cuticular closure demonstrating reduced nipple–areolar
complex
Following a tumescent period of 20–25min, the adipose
tissue is harvested by conventional liposuction using 3-mm
cannulas with a vacuum pump, applying 250–300mmHg of
pressure. The harvested fat is centrifuged at 3000rpm for
3 min to obtain a puried and viable fat donor graft pool.
Percutaneous fasciotomies are rst performed in the lower
pole of the breast by making an incision with a 14-gauge
Fig. 27.6 A 2-mm Toledo cannula with a v-shaped tip for release of
constricting bands (Black & Black Surgical, Tucker, GA, USA)
(Courtesy of Black & Black Surgical, ©2022 Tucker, GA, USA, All
Rights Reserved)
catheter followed by the use of a 2-mm-diameter Toledo cannula with a V-shaped tip to release the adherent tissues in the
constricted lower pole (Black & Black Surgical, Tucker, GA
USA) (Fig.27.6).
Fat is then reinjected into the breasts through three designated sites located at the inframammary fold, anterior axillary line, and upper pole (Fig.27.7) using 3-cc syringes with
9-cm-long, 1.6-mm-diameter Coleman style 2 concave, or
straight blunt cannulas (Mentor, Santa Barbara, CA, USA).
Fat grafting is performed in layers from deep to supercial,
beginning above the pectoralis major muscle to the subcutaneous tissues, just until skin turgor is achieved to prevent
ischemia of the grafted cells. The injection sites are covered
27 Percutaneous Fasciotomy andFat Grafting fortheCorrection oftheTuberous Breast Deformity
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Fig. 27.7 Release of the
lower breast pole and fat
grafting technique
379
with Steri-Strips (3M, Maplewood, MN, USA). Dressings
consisting of paper tape are applied over and around the
breast mound as a soft splint to minimize edema without
constricting blood ow to the grafted tissue.
The postoperative protocol consists of an ofce visit at
7days postoperative for removal of the dressings and evaluation. Suture removal from the liposuction sites is performed
2weeks following surgery. Patients are evaluated at 1month,
3months, 6months, and 12months.
27.8 Prognosis/Results
Approximately 70% retention of volume is typically obtained
by 3months following each fat grafting procedure, as determined by physical examination and review of postoperative
photographs. There is generally a high satisfaction rate secondary to reshaping of the breast mound, reduction of areolar herniation, and increased breast volume [14] (Figs.27.8,
27.9, and 27.10).
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abc
def
P. Gutierrez-Ontalvilla and N. S. Naidu
Fig. 27.8 (a–f): Preoperative and postoperative views of a 15-year-old girl who underwent two sessions of fat grafting with correction of the size
and herniation of the nipple–areola complex. The patient is shown prior to surgery and 13months following her second operative session
27 Percutaneous Fasciotomy andFat Grafting fortheCorrection oftheTuberous Breast Deformity
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abc
def
381
Fig. 27.9 (a–f): Preoperative and postoperative views of a 15-year-old girl who underwent two sessions of fat grafting with correction of the size
and herniation of the nipple–areola complex. The patient is shown prior to surgery and 20months following her second operative session
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