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P. Gutierrez-Ontalvilla and N. S. Naidu
Fig. 27.10 (a–f): Preoperative and postoperative views of a 27-year-old woman who underwent one session of fat grafting with correction of the
size and herniation of the nipple–areola complex. The patient is shown prior to surgery and 12months following surgery
27.9 Complications
Severe complications including infection, dehiscence, or
hematoma have not been observed [14]. Asymptomatic oil
cysts (less than 10mm in diameter) may appear and can be
detected with routine ultrasound. Ultrasound examinations
by a radiologist specializing in breast imaging are recommended as part of a standard protocol beginning at 6months
postoperative. Other complications include palpable, supercial, and painful nodules secondary to fat necrosis which
can be excised under local anesthesia. Scar widening requiring revision and the need for additional volume are additional possibilities.
27.10 Conclusions
Autologous fat grafting in conjunction with percutaneous
fasciotomy is a validated and versatile tool in aesthetic breast
surgery. When used in conjunction with the reduction of the
nipple–areolar complex and breast tissue herniation, it
becomes especially useful for the treatment of tuberous
breast deformity. This technique is especially applicable in
teenage girls who suffer from the social stigmata of breast
deformity, but for whom the placement of implants or use of
aps would be premature given the potential for further
breast growth. It is a reliable method which produces excellent results with minimal complications.
27 Percutaneous Fasciotomy andFat Grafting fortheCorrection oftheTuberous Breast Deformity
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383
References
1. Nahabedian MY.Breast deformities and mastopexy. Plast Reconstr
Surg. 2011;127(4):91e–102e.
2. Latham K, Fernandez S, Iteld L, etal. Pediatric breast deformity. J
Craniofac Surg. 2006;17:454–67.
3. Forster NA, Kunzi W, Giovanoli P. The reoperation cascade after
breast augmentation with implants: what the patient needs to know.
J Plast Reconstr Aesthet Surg. 2013;66:313–22.
4. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited:
safety and efcacy. Plast Reconstr Surg. 2007;119:775–85.
5. Dessy LA, De Santo L, Onesti MG, Fallico N, Mazzocchi
M.Tuberous breast and predisposition to breast deformity in consanguineous. Breast J. 2018;24(1):51–4.
6. Grolleau JL, Lanfrey E, Lavigne B, Chavoin JP, Costagliola
M. Breast base anomalies: treatment strategy for tuberous
breasts, minor deformities, and asymmetry. Plast Reconstr Surg.
1999;104:2040–8.
7. Klinger M, Caviggioli F, Giannasi S, Bandi V, Banzatti B, Veronesi
A, etal. The prevalence of tuberous/constricted breast deformity in
population and in breast augmentation and reduction mammaplasty
patients. Aesthetic Plast Surg. 2016;40(4):492–6.
8. Klinger M, Caviggioli F, Klinger F, Villani F, Arra E, Di Tommaso
L.Tuberous breast: morphological study and overview of a borderline entity. Can J Plast Surg. 2011;19(2):42–4.
9. von Heimburg HD, Exner K, Kruft S, Lemperle G.The tuberous
breast deformity: classication and treatment. Br J Plast Surg.
1996;49:339–45.
10. Rees TD, Aston SJ. The tuberous breast. Clin Plast Surg.
1976;3(2):339–47.
11. Ribeiro L, Canzi W, Buss A Jr, Accorsi A Jr. Tuberous breast: a new
approach. Plast Reconstr Surg. 1998;101(1):42–50.
12. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas D,
Lambrinaki N, Ioannidou-Mouzaka L. Aesthetic reconstruction of the tuberous breast deformity. Plast Reconstr Surg.
2003;112(4):1099–108.
13. Teimourian B, Adham MN. Surgical correction of the tuberous
breast. Ann Plast Surg. 1983;10(3):190–3.
14. Gutierrez-Ontalvilla P, Naidu NS, Blanco EL, etal. Autologous fat
grafting with percutaneous fasciotomy and reduction of the nipple–
areolar complex for the correction of tuberous breast deformity in
teenagers. Aesthetic Plast Surg. 2020;44(2):264–9.
15. Silva-Vergara C, Fontdevila J, Weshahy O.Fat grafting technique,
a paradigm shift in the treatment of tuberous breast. World J Plast
Surg. 2018;7(1):72–7.
Postbariatric Breast Reshaping andFat
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Grafting
VincenzoVindigni, PaoloMarchica, andFrancoBassetto
Contents
28.1 Introduction to Body Contouring and Breast Reshaping in Massive Weight Loss Patients 385
28.2 Physiopathology of Breast Deformity, Surgical Indication, and Contraindication 385
28.3 Surgical Techniques and the Role of Fat Grafting 387
28.4 Fat Grafting Technique 390
28.5 Fat Grafting and Complications 391
28.6 Conclusion 392
Further Reading 393
28
28.1 Introduction toBody Contouring
andBreast Reshaping inMassive
Weight Loss Patients
Massive weight loss patients (MWL) number is increasing,
especially due to the development and the request of bariatric
surgery, hence the problems related to redundant skin and
soft tissues following massive weight loss. An important
weight loss involves all the body districts, from the abdomen
to the thighs, the arms, the face, and the breasts as well. A
MWL patient, thus, asks for body contouring surgery in
order to reshape his body morphology, to resolve functional
and aesthetic problems. The redundant soft tissue, indeed,
may cause functional impairment in wearing clothes, doing
physical exercise, promoting the development of skin infection, and determining social concern with regard to the image
of the own body. Therefore, an MWL patient deserves the
chance to restore his body natural appearance at cost, however, of facing with scars.
The mammary gland is a very important anatomical site
with regard to woman due to its role in the canons of beauty
and, nowadays, is gaining importance for man as well. The
V. Vindigni · P. Marchica (*) · F. Bassetto
Clinic of Plastic and Reconstructive Surgery, University of Padua,
Padua, Italy
e-mail: vincenzo.vindigni@unipd.it; franco.bassetto@unipd.it
MWL population usually presents a ptotic, deated breast,
medialized (sometimes lateralized) nipple-areola complex
and chest or axillary rolls. Hence, MWL patients ask to the
plastic surgeons to reshape the body, and the breast surgery
is one of most requested procedures for both male and female
patients.
28.2 Physiopathology ofBreast Deformity,
Surgical Indication,
andContraindication
Post-bariatric patients present a reduction in collagen, while
the elastic bers remain unchanged. This leads to a mismatch
in these components ratio that nally determines a soft tissue
ptosis which involves all body district, including the breast.
Traditional techniques are often inadequate in massive
weight loss patients because of the extent of the deformity,
the lack of structural volume or support, and the inelastic
skin envelope. The traditional breast reshaping focuses on
the skin envelope, which is resected, tightened, and
redraped over the breast mound and none or minimal surgery is provided to the parenchyma. In MWL patient,
instead, more attention has to be paid with regard to the
glandular reshaping, to minimize the incidence of recurrent
ptosis, which is so frequently relapsing, and to maintain the
shape (Fig.28.1).
© 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_28
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a
d
Fig. 28.1 Auto-augmentation using dermoglandular ap and fat grafts.
The dermoglandular ap is prepared (a) and xed in the desired position (b, c). The periareolar and vertical incisions are approximated (d).
To understand the deformity of an MWL patient’s breast,
the surgeon should consider: the volume of the gland, that is
usually reduced, thus the deation, except for the cases of
macromastia; the degree of ptosis, which should be mild,
moderate, or severe, according to Regnault; the NAC position, which is frequently medialized; the condition of the
skin envelope that is usually stretched and anelastic and less
susceptible to skin retraction, thus it needs a skin resection
accompanied to a parenchymal reshape to maintain the
breast nal shape; nally, the associated chest, axillary, and
abdominal deformities (chest and axillary rolls, redundant
upper abdomen skin) that may jeopardize the nal result, if
not considered and eventually treated.
The choice of the right technique is demanded to the
surgeon who can take advantages from the Pittsburgh
Rating Scale (PRS). This classication described by Song
in 2005 recommends the options to consider for surgical
improvement and it is applied to all body districts. With
regard to the breast, it classies a range of breast deformities occurring after MWL and provides an objective scoring system which is based on the severity of the contour
deformities.
The PRS classies as Grade 0, the patients which present
normal breast ndings and they do not need any surgery. The
Grade 1 consists in Ptosis grade I and II or severe macromastia. These patients need a traditional mastopexy, reductive
mammoplasty, or augmentation techniques depending on the
single case. The Grade 2 presents a severe ptosis (grade III)
or a moderate volume loss or a constricted breast. Such
Excess of skin is removed (e). Fat grafts are used to improve the volume
and the prole of the breast (f)
patients need to be addressed with a traditional mastopexy
with or without an augmentation mammoplasty. Finally, the
Grade 3 consists in severe lateral rolls with or without a
severe volume loss and loose skin. These patients are the
most difcult to deal with, and the breast mound needs a
complex parenchymal reshaping, even with dermal suspension and sometimes an auto-augmentation techniques may
be considered.
The Pittsburgh Rating Scale
Area Scale Preferred procedure
Breasts 0 Normal None
1 Ptosis grade 1–2 or
severe macromastia
2 Ptosis grade 3 or
moderate volume loss
or constricted breast
3 Severe lateral roll and/
or severe volume loss
with loose skin
Song AY, Jean RD, Hurwitz DJ, Fernstrom MH, Scott JA, Rubin
JP.A classication of contour deformities after bariatric weight loss:
the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005
Oct;116(5):1535–44; discussion 1545–6. https://doi.org/10.1097/01.
prs.0000182606.92069.13.
Traditional mastopexy,
reduction, or augmentation
techniques
Traditional
mastopexy±augmentation
Parenchymal reshaping
techniques with dermal
suspension, consider
autoaugmentation
Not all patients present with these deformities after MWL
and each of them must be evaluated individually. Indeed, the
surgical treatment of the breast must be tailored to the single
case.
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387
In addition to the breast physical ndings described by
the PRS, the surgical indications to breast reshape in MWL
patients include a stable weight control within the previous
6months and the achievement of a balance in the nutritional
status. As a matter of fact, most of MWL patients had weight
loss after bariatric surgery, thus they need of a postoperative
recovery time to adjust their gastrointestinal physiology and
resolve the eventually occurred nutritional decits.
A globally considered guidelines to body contouring surgery after massive weight loss were released by BAPRAS
(British Association of Plastic, Reconstructive and Aesthetic
Surgeons) in 2017 and, to date, they are the most complete
recommendations about this surgery. An adequate preoperative BMI seems to be one of the most important factors
pivotal to obtain a successful outcome. Absolute contraindications to breast reshaping are very few and consist in active
breast cancer, active skin infection, and systemic disorders,
which preclude a general anesthesia. Most of the contraindications are classied as relative and consist in a BMI higher
than 35kg/m2, while a BMI≤30.0kg/m2 is recommended to
obtain a stable and good result. Smoking is considered a
negative prognostic factor in conditioning the outcomes, but
it is not an absolute contraindication to surgery. Patients are
advised to quit smoking at least 4weeks before surgery and
avoid tobacco use up to 4weeks after surgery, to reduce the
complication rate. Finally, before surgery, it is appropriate to
avoid the assumption of medications that increase the risk of
bleeding or cause an increase in thrombotic risk. A wound
healing disorder and systemic disease may represent a relative contraindication; thus, they should be carefully investigated, and the patient stabilized before surgery.
Such a real query is whether the fat grafting is to be performed. Little asymmetries among the breast which are not
solvable with parenchymal and skin reshaping techniques or
cases with patient refusing breast implants or the ones who
had little benets obtained from auto-augmentation aps
may be the ideal candidates to fat grafting. Finally, its use in
oncological patients is still debated by literature and last discussions and experts’ positions are listed below.
28.3 Surgical Techniques andtheRole
ofFat Grafting
After the patient is individually staged and investigated for
what it may concern the breast deformity, the technique is
chosen and tailored to the single breast.
As discussed by Song, several techniques may be used to
reshape the breasts, depending on breast physics and these
may be divided into:
Augmentation techniques: a breast implant (silicone or
polyurethane-coated silicone prosthesis) is placed in a subglandular, submuscular, subfascial, or dual plane position
and sometimes associated with a mastopexy technique; this
category allows to act on the breast mound and on the skin
envelope (Fig.28.2).
Mastopexy and reductive mammoplasty: the breast is
lifted and reduced in volume, if needed and both the parenchyma and the skin envelope are reshaped to improve the
aesthetic and functional outcome. A mild deformity with a
minimal ptosis may be treated with a periareolar reduction
mastopexy as described by Benelli. This technique allows a
parenchymal reshape through a periareolar incision and performing a criss-crossing of the medial and lateral lower
quadrants of the breast, below a superiorly based NAC ap.
A breast implant may be positioned through the same access
if needed. Benelli’s technique has the advantages of hiding
the scar along the areolar boundaries. However, the nippleareola complex may be slightly repositioned due to a limited
skin excision (crescent or donut excision) and an excessive
resection may cause a widening of the scar and of the new
areola. Hence, a round block suture may limit the tension on
the wound edges, though determining a attening of the new
breast. Moderate deformities need to be addressed with more
aggressive techniques, which consequently need longer and
more visible scars such as vertical incision techniques
(Lassus, Lejour, etc.). A vertical technique incision involves
a periareolar and a vertical inferior pole incisions, which
allow to treat a major ptosis and a better parenchymal reshaping. It may be combined with an auto-augmentation technique or a breast implant positioning or, if needed, it allows
to perform a reductive mammoplasty (Fig.28.3). However, it
has the problem of a late aesthetically pleasant shape because
an excessive projection of the upper pole is almost always
present in the rst 2–3months postoperatively and the NAC
may initially be facing down or present a bottoming out
deformity. Finally, a severe deformity may only be addressed
with an inverted-T incision pattern to excise horizontal and
vertical skin excess and allow to reshape a severe deformed
breast. Different techniques may be used, and among them
the superior pedicle technique by Pitanguy is the best known.
These techniques are characterized by a wide freedom of
resection in each quadrant of the breast with a better chance
to adequately reshape the gland, at cost of more extended
scar (periareolar, vertical, and horizontal along the inframammary fold).
Autoaugmentation techniques, with eventual dermal
suspension: these techniques include the procedures that
take advantages of the auto-prostheses concept (part of breast
parenchyma is used in order to increase the volume and the
projection of the mammary gland, as the inferior pedicle
technique described by Ribeiro) and may be combined with
dermal or dermoglandular aps that are anchored to the chest
wall (Fig.28.1).
Fat grafting represents an additional auto-augmentation
technique (Fig.28.1). The most recent International Expert
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Fig. 28.2 Breast augmentation with subglandular round prostheses. Preoperatory images (a, b) and postoperatory results after 1year (c, d)
Panel Consensus on Fat Grafting of the Breast in 2019 produced a document in which the authors prepared a set of ten
“key statements” that have been discussed in a dedicated
face-to-face session during the meeting. Despite this consensus conference presented some limitations (each key
statement was not assessed with a standardized methodology and only the Level of Evidence (LoE) according to
Oxford Criteria was evaluated) and remained expression of
a group of expert and not guidelines for clinical practice, it
provided some advice to plastic and reconstructive surgeons approaching fat grafting. We report three of them,
which in our opinion represent the most important statements emerged from this consensus, with regard to the use
of fat grafting in aesthetic breast surgery and fat grafting
oncological safety:
tation) or for minor renements. Fat grafting could be
also considered as an alternative to implants for breast
augmentation with adequate patient information about the
achievable results and the number of sessions needed”
(LoE IV).
– “Oncological concerns have risen with the use of fat
grafting for breast reconstruction. There is an evident
contradiction between experimental and clinical ndings
about the oncological safety of fat grafting. The very
complex interplay “in vivo” is not simulated in “in vitro”
studies. Fat grafting could be considered a safe procedure
after breast-conserving treatment and mastectomy for
breast cancer treatment with an adequate postoperative
surveillance. Prospective clinical trials with adequate fol-
low- up are awaited to denitely conrm the safety of fat
grafting in BRCA-mutated patients (both following risk-
– “Fat grafting is a useful tool in aesthetic breast surgery in
association to implants (composite/hybrid breast augmen-
reducing surgery and surgery for the treatment of breast
cancer)” (LoE III).
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abc
def
389
Fig. 28.3 Mastopexy with vertical scar. Preoperatory images (a–c). Postoperatory results after 2years (d–f)
– “Fat grafting is a safe procedure when considering the
impact on breast cancer detection and surveillance if a
proper technique is used and the surveillance is granted
by dedicated breast imaging specialists” (LoE III).
Macroscopic benets of fat grafting may be described as
the capability of lipolling in dening the details of a reconstructed breast, where the implants or an autologous ap do
not completely achieve the desired shape. Indeed, it is very
difcult to deal with breast asymmetries solely through the
Why has the fat grafting reached so much importance in
breast surgery? Molecular and cellular benet of fat transplantation was rst described by Coleman in the face, followed by its application in other body districts. Subsequently,
Yoshimura discussed lipolling for breast augmentation,
based on its cellular composition. Indeed, grafted fat tissue
contains adipogenic progenitor cells (adipose stem cells or
ASCs) and also multipotent stem cells able to differentiate
into different tissues. Some of these cells may be able to
build the environment to allow the fat engrafting, such as
endothelial cells and vascular mural cells, promoting angiogenesis and fat survival. Finally, the ASCs produce angiogenic growth factor in response to hypoxia, thus they are able
to stimulate angiogenesis in a damaged site, such as happens
for irradiated tissue (e.g., lipolling after radiation therapy).
In patients such as MWL, adipose tissue transplantation,
therefore, plays a trophic role in the restoration of a heavily
damaged tissue rst by weight gain and then by massive
weight loss, perhaps associated with nutrients depletion.
use of implants. Fat grafting results effective where the
implants fail. Finally, as for oncological patients, even MWL
patients often present a reduced skin ap thickness which
corresponds to a visible implant borders when placed in a
subglandular plane. Therefore, the solution may be represented by a submuscular pocket. However, despite submuscular implant placement provides additional tissue coverage
and support to the prosthesis and reduces capsular contraction rate, it often requires pectoralis major muscle release
from lower sterno-costal insertions, thus violating an anatomic structure, and it could be associated with an annoying,
albeit initial, discomfort, with a more painful postoperative
course, with a higher risk of bleeding and the risk of animation of the pectoralis major muscle with an upward thrust of
the prosthesis, which in patients practicing intense physical
activity to maintain weight loss may be more noticeable and
therefore less acceptable. Hence, the attempt to continue
using the subglandular implant required the aid of fat transplantation. Indeed, fat grafting plays a role in camouaging
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and masking the implant borders when these are placed in
the more anatomic subglandular plane, especially but not
limited to, the upper and medial breast quadrants, reducing
the unnatural appearance and the palpability of the
prosthesis.
28.4 Fat Grafting Technique
Autologous fat grafting may be performed under general
anesthesia or under local anesthesia with or without sedation. Primary donor site is often referred to the abdomen, but
other sites are available as arms, anks, or gluteal area. These
sites are quite available in MWL patients and easier to exploit
compared with non-MWL patients. No signicant differences are reported in literature with regard to fat viability for
any donor site between the normal weight and overweight
patients.
The harvesting is conducted, after inltration of a variable
mixture of normal saline, epinephrine, and local anesthetic
depending on surgeon preference (local anesthetics may
modulate isolated preadipocytes viability rates, thus not all
surgeons use them in donor site inltration), by manual aspiration with 2- or 3- or 4-millimeters cannula (increased cell
viability is demonstrated when using a 4-mm cannula compared with a 2- or 3-mm devices). The attached syringe may
vary from 10 to 60cc, and the generated pressure inside it
may inuence the ASCs availability and viability as reported
in literature (lower pressures <250mmHg increase cell viability and survival). Centrifugation (usually 3000rpm for
3min as described by Coleman) or decantation eventually
followed by washing and ltration may be performed.
Several studies report that adipocyte counts are signicantly
greater in decanted lipoaspirates compared with centrifuged
lipoaspirates.
Delivering is performed in the site of injection, usually in
subcutaneous space and sometimes additional injection into
subpectoral or retroglandular spaces. 1–2mm Coleman cannulas and 10 cm3 syringes are used, though some authors
prefer to use 12/14 gauge needles (Figs.28.4 and 28.5). Fat
transfer is performed blindly both in subcutaneous, subpectoral, or retroglandular spaces at the end of the procedure.
Subcutaneous fat grafting is easier to perform with either
straight or blunt cannulas, and it presents less risk of impairing the implant. On the other hand, it is necessary to be careful to do not damage the implant when delivering subpectoral
or retroglandular fat. This grafting is performed through the
use of curved, blunt, and large-caliber cannulas that are rst
abc
def
Fig. 28.4 Auto-augmentation using dermoglandular ap and fat grafts. Preoperatory images and surgical project (a–c). Postoperatory results after
2years (d–f)
28 Postbariatric Breast Reshaping andFat Grafting
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de f
391
Fig. 28.5 Auto-augmentation using dermoglandular ap and fat grafts and abdominoplasty. Preoperatory images and surgical project (a–c).
Postoperatory results after 2years (d–f)
advanced on the ribs, which represent a safe point of refer-
28.5 Fat Grafting andComplications
ence to avoid deepening into the thorax, and then made to
proceed retroglandular or subpectoral, around the implant,
also through the help of the sensory feedback that the prosthesis provides to the advancement of the blunt cannula. This
procedure is not without risks for the prosthesis and requires
a certain degree of expertise, but it provides good results.
The use of fat grafting in subpectoral space does not allow to
place a suction drain in the implant pocket.
Adipocyte viability seems to be inuenced by the cannula
caliber (increased with 2.5-mm cannula), but no differences
have been found with regard to needle gauge, as reported by
literature.
After fat injection, dressing should be maintained with a
mild compression to favor the fat survival with a medical bra
for 4weeks, night, and day. Antibiotic therapy should be preoperatively administered to prevent infection and continued
postoperatively if prostheses are used.
Fat grafting complications are common to all districts but if
considered for the breast they are burdened by the oncological risk and cancer surveillance, as lipolling may potentially interfere with breast cancer detection, as previously
discussed. Most common complications are palpable indurations and cysts, ecchymosis after treatment, and pain, while
less common are represented by hematoma, infection, and
seroma (Fig.28.6).
Radiological changes frequently occur. As reported by
Expert Panel Consensus on Fat Grafting of the Breast in
2019, autologous fat grafting may be considered a safe procedure in aesthetic breast surgery and after breast cancer surgery with an adequate postoperative surveillance.
A recent systematic review discussed the complications
occurring after fat grafting for cosmetic breast augmentation, thus without considering other procedures or medical
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Fig. 28.6 Complication of fat grafts. Blue arrows point area of liponecrosis (a, b). The total removal of necrotic fat grafts (c) required total recon-
struction whit prostheses (d)
condition (breast reconstruction with radiotherapy, apbased reconstruction, and implant-based breast augmentations) associated with fat grafting that may jeopardize the
outcomes and overestimate the complications rate. The
sample included 2073 patients, evaluating the rate of major
and minor complications. Among major complications,
0.5% patient developed hematoma, 0.6% developed infec-
ing safe and effecting as an alternative to breast augmentation. Donor site infection, fat embolism, and pneumothorax
are considered rare complications, while donor site deformation may be ascribed to a poor surgical technique. No
studies are available with regard to fat grafting complications rate in MWL patients compared to non-MWL
patients.
tion, and 0.1% developed seroma. None of them required
revision surgery. Minor complications rate was 2.0% for
palpable cysts, most of them treated with aspiration.
28.6 Conclusion
Radiologic changes were also investigated: oil cysts 6.5%,
calcication 4.5%, and fat necrosis 1.2%. Only 3.2% need
biopsy to exclude malignant changes, and none of them
had therapeutic consequences, thus conguring fat graft-
Nowadays, the autologous fat grafting is considered a natural
ller able to provide volume enhancement, contour correction, and regenerative capability, and it results in a promising
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