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34 Head and Neck Reconstruction with Autologous Fat: The Versatility of Autologous Fat Graft in Correction of Facial Deformities…
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or early recurrence and also to allow enough time for the
tissues to heal following oncologic treatment and allow a
clear appreciation of the extent of the defect following resolution of acute posttreatment edema.
The fat grafting technique is based on surgeon preference.
Different techniques are described in the literature, and it is
hard to comment on the complication rates and effectiveness
based on technique. There is also conicting evidence
regarding cell populations present within the graft based on
the processing technique.
Autologous fat grafting seems to be less effective when
the underlying bony structure has been removed, while it
works as useful adjunct to correct minor contour defects
after bone-free ap or graft reconstruction. When fat is
injected into facial soft tissues not supported by bone, the
volume will take the path of least resistance. For example, in
cheek deformities following maxillectomy, some of the
increase in volume will be apparent intraorally or within the
maxillectomy cavity because the oral mucosal tissues are
softer and more pliable, whereas irradiated skin is stiff and
resistant to changing shape. In our clinical practice, we use
adipo-fascial-free aps for substantial defects and we reserve
autologous fat grafting for smaller defects or as an adjunct to
bone or soft-tissue-free ap reconstruction. We feel that
adipo-fascial-free aps provide a more predictable restoration of facial contouring, often in a single stage. Serial autologous fat grafting may have a role in patients who have
sizable defects but are not good candidates for microvascularfree ap reconstruction.
In addition to its utility in treating aesthetic defects, autologous fat grafting has recently attracted attention because of
important biological properties that underlie its potential for
regenerative medicine [3, 4]. These studies support the idea
that adipose tissue enhances angiogenesis by secreting various multipotential stem cell growth factors. This could be
critical for previously irradiated areas, which suffer irreversible tissue damage, decreased vascularization, and altered
blood vessel morphology, leading to tissue ischemia. Fat
grafting could promote increased vascularization and revitalization of the interstitial tissue, resulting in improved elasticity and tissue quality.
34.2 Surgical Procedure
The procedure of head and neck lipostructure consists of
three distinct phases performed in a single surgical time:
1. Fat Tissue Harvesting
2. Fat Tissue Processing
3. Lipotreated Tissue Injection
34.2.1 Fat Tissue Harvesting
Each patient was examined preoperatively in orthostatic
position with the pinch test, to precisely evaluate and draw
the area to be lipoaspirated.
The ideal donor site, also in children, is represented by the
abdomen because of its ease of access and availability; it is
unique and median (for which we do not need to take bilateral sample as from the hips, thighs, and buttocks to avoid
morpho-volumetric asymmetries). Further, the abdominal
area as donor site allows to place the patient in supine position and easily allows the injection time.
In very thin children, the supragluteal region and inner
knees are the best donors of adipose tissue, but requires bilateral sampling to preserve the contouring of the buttock; furthermore, they require to move the position with the child’s
pronation-supination. In case of severe asymmetries and
great volumetric soft tissue decit, multiple donor sites are
evaluated.
The rst step is the inltration in the donor site of a solution composed of Epinephrine 2mcg/mL in saline solution
(1:500), using a 17-Gauge cannula connected to the
Luerlock® syringe.
After 10min, lipoaspiration of an adequate amount of fat
tissue (depending on the clinical defect of the patient) is performed in a standardized fashion of the liposuction through a
millimetric skin incision. Fat is harvested from the selected
area using manual suction with a 20 cc syringe Luerlock®
and a 3mm 13-Gauge blunt cannula.
34.2.2 Fat Tissue Processing
Processing of the harvested adipose tissue is carried out in a
closed Luerlock® syringe system.
The processing mechanism consists of a washing procedure, using the Ringer’s lactate solution and a gradual sedimentation by gravity and shakering, as a method to remove
nonviable components of the lipoaspirate and impurities
(blood, oil, and cell debris), producing an injectable uid
containing puried fat graft and many pericytes and mesenchymal stem cells. Thanks to this procedure, fat tissue is
microfragmented gently and washed from proinammatory
oil and blood residues, without enzymes or other additives.
Furthermore, to obtain a gradual reduction in the adipose
tissue clusters, we usually use Tulip’s TRUE NanoFat System
(TNF™); nanofat obtained is ideal to promote tissue pliability restoration and remodeling scars thanks to the high concentration of viable regenerative cells.
Processed microfat and nanofat micro-aliquots, further
reduced by a sizing transfer 2.4mm, 1.4mm, or 1.2mm, are
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to be placed in selected anatomical areas, as vocal folds,
paraglottic space, palatoplasty scars, intradermal plane, in
multiple tunnels to enhance graft neovascularization, and tissue regeneration.
34.2.3 Lipotreated Tissue Injection
The processed puried fat graft is then injected in head and
neck area, following the principles of structural fat grafting.
Multiple access sites and a fan-like pattern technique using
1.4 mm and 1.8 mm blunt cannulas were used to transfer
small aliquots of fat into various depths of the soft tissue
(from the dermis to the muscular fascia or muscle). To obtain
a volumetric improvement, a three-dimensional network of
tunnels is created to improve the contact between the graft
and the native adipose tissue, in order to maximize its vitality
and its clinical effects. In case of volumetric restoration, we
usually perform a 30% overcorrection to obtain symmetry
with contralateral side because of the unpredictable loss of
volume over time.
In selected case (functional disorders and brotic tissues),
traditional fat grafting can be combined to nanofat [5] to promote tissue pliability restoration and remodeling scars thanks
to the high concentration of viable regenerative cells.
Nanofat micro-aliquots are to be placed in the supercial
plane (intradermic layer or submucosal plane), in multiple
tunnels to enhance graft neovascularization and tissue regeneration, injecting with 27G and 30G needles, connected to a
Luerlock® system syringe.
34.3 Clinical Applications
34.3.1 Craniofacial Malformations
Patients with congenital cranio-facial malformations are
generally treated with traditional surgery, as orthognathic
surgery and/or additional procedures (genioplasty, alloplastic implants, injectable absorbable llers) with satisfactory
results. However, despite achieving skeletal symmetry with
orthognathic procedures, noticeable facial asymmetry may
persist in soft tissues, and these conditions can be satisfactorily treated with lipolling renement procedures.
Lipostructure procedure depends on the proper features of
the malformation, including facial asymmetry in patients
with hemifacial microsomia and the post-surgical sequelae
of cleft lip and palate.
Treacher Collins syndrome is a rare autosomal dominant
congenital disorder, featured by severe hypoplasia of the
facial skeletal particularly the maxilla, mandible, and
zygoma, resulting in hypoplasia of the overlying soft tissues.
Abnormal position and shape of the ear are common, often
accompanied by conductive hearing loss as well as
ophthalmic abnormalities such as downward slanting of palpebral ssures.
Multistep lipostructure in this kind of patient can contribute to achieve an acceptable facial contouring (Fig.34.1).
Malformative patients, often had undergone multiple reconstructive surgeries, presenting adherence to the underlying
tissue at the scar after skeletal surgery or cleft repair, so need
of scar releasing and rigottomies before fat transplantation.
Nanofat injection could optimize the soft tissue quality.
In the case of cleft lip and palate sequelae, autologous fat
grafting can improve scarring and increase upper lip volume.
In these cases, fat graft can restore paranasal hypoplasia too.
Further, autologous fat graft is an optimal option for velopharyngeal incompetence, often related to cleft palate.
34.3.2 Velopharyngeal Incompetence
Velopharyngeal incompetence (VPI) is a multifactorial decit of resonant speech control, nasalence, and sometimes loss
of optimal intraoral pressure to obtain orally directed speech
sounds, leading to marked relationship disorders, especially
in scholar age. Etiological causes can be structural and
genetic, functional and neurogenic, mechanical interference,
and acquired factors.
Nowadays, the most common cause is the cleft palate,
isolated or associated to cleft lip.
Traditional surgical pharyngoplasty is mandatory in
severe conditions, when the gap is too large and velopharyngeal closure is inferior to 50%, and when the contraction of
the velum is absent.
In mild and moderate cases, the augmentation of the lateral and posterior pharyngeal walls (named Passavant’s
crest) with autologous fat graft can be sufcient to compensate mild cases of velopharyngeal incompetence and resolve
hypernasal speech and air leak.
Different materials have been described during the past
decades, but nowadays the gold standard remains autologous
fat graft.
We usually perform autologous fat grafting in cleft patients,
about 5years old, underwent to speech therapy without satisfactory results in the resonance impairments. The surgical procedure requires general anesthesia. The most frequent donor
site in children is the abdomen, followed by the thigh and the
hips; autologous fat is processed by washing and decantation
closed technique, without centrifugation. The selected autologous fat was injected into posterior pharyngeal wall (midline,
Passavant’s crest, soft palate, palatopharyngeal arch, uvula)
using blunt 18G cannula with microtunnel technique. Usually,
cleft patients are treated with a single injection; the amount of
fat injected in the posterior pharyngeal wall ranged from 6 to
12mL (Fig.34.2). Microfat can be combined to nanofat injec-
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Fig. 34.1 Full face fat grafting in Treacher Collins syndrome (frontal,
lateral, and submental-vertix view). A 33-year-old woman affected by
Treacher-Collins syndrome, with a severe facial asymmetry even after
multiple orthognatic surgeries, characterized by right hemifacial hypo-
plasia. Postoperative outcome after one session of structural grafting
procedures (follow-up time: 14 months). Note the improvement of
facial symmetry, malar area, and mandibular prole
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a
b
c
Fig. 34.2 Fat grafting in velopharyngeal incompetence in cleft patient. (a) Preoperative view. (b) Immediate postoperative view after autologous
fat grafting. (c) Main injection sites for velopharyngeal incompetence
tion to promote palatal mobility and vibration. We inject with
34.3.3 Systemic Sclerosis
27G and 30G needles, connected to a Luerlock® system
syringe for palatal surgery. The treated patients presented
good postoperative intelligibility and phonation, reduction of
hypernasality, and improvement of postoperative nasalence.
Postoperative nasobroscopy is mandatory to assess the
degree of velopharyngeal closure during phonation and feeding and to guide speech therapist for postoperative rehabilitation. Regenerative potential of fat grafting in comparison to
other injectable material presents a higher amount of stem
cells, favors tissue regeneration, and does not compromise
velopharyngoplasty and other traditional surgical treatments
when autologous fat grafting does not determine expected
outcomes.
Systemic sclerosis (SSc) is a rare systemic autoimmune connective tissue disease of unknown etiology, characterized by
cutaneous and visceral brosis; it is a heterogeneous pathology, due to an immunological overactivation of the broblasts that led to a progressive cutaneous and internal organ
brosis. Skin involvement is constant and can be variable.
Patients with systemic sclerosis often complain of aesthetic
and functional concerns; facial scleroderma consists of aesthetic disgurement and limited facial expression with a
mask-like stiffness of the face. Further, the loss of elasticity
and the thickening of the skin in the perioral area, furrowing
and narrowing of the oral aperture, leading to mouth opening
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reduction that interferes considerably with life’s basic functions such as eating, speaking, oral hygiene, and professional
dental care. Furthermore, the clinical evolution of the disease, induces salivary gland brosis and reduced saliva production, leading to the pathognomonic xerostomia (dry
mouth). Then, facial manifestations of systemic sclerosis are
extremely disabling and severely impair the patients’ selfimage and compromise their quality of life.
There are limited treatment options for scleroderma xerostomia and microstomia, as stretching exercises, Intense
Pulsed Dye light and CO2 laser, with ineffective results.
Thanks to a lling effect and regenerative potentials due
to their adipose-derived stem cells (ASCs) content, autologous fat grafting represents nowadays an effective therapeutic alternative of the symptoms and of the clinical presentation
of the disease.
Mouth opening handicap is a pathognomonic feature in
the systemic sclerosis due to the alterated skin and mucosal
biophysical properties (Rodnan skin score). Lipolling treatment in plays a key role in SSc patients’ satisfaction, both for
the aesthetic effects (improvement of the patients’ appearance) and for the functional aspects related to possible
changes in the collagen pattern and content (Fig.34.3).
mal phonation time (MPT), showing improved glottic closure despite a limited amount of fat resorption. The
regenerative treatment reporting also a subjective satisfaction
of the treated patients. Alternative treatment for vocal fold
augmentation is the injection of calcium hydroxyapatite
(CaHA); the key point of fat transplant in comparison to
other injectable substances is its regenerative potential
related to adipose-derived stem cells and growth factors.
Further, the combination of nanofat can be a promising
adjunct to traditional fat augmentation to improve elasticity
of the delicate multilayered structure of the vocal fold and to
enhance its vibratory capabilities during eloquence.
Therefore, fat grafting is an effective and biological ller
also for permanent vocal fold injuries.
The goal is to obtain a three-dimensional network of viable adipocytes that will receive more nourishment, reducing
the necrosis areas and, then, the risk of reabsorption and oily
cists.
Thanks to its low invasiveness, low rate of complications
and its regenerative potential, autologous fat graft can be
considered a current, safe and effective technique for a more
customizable facial contouring, restoring volume loss and
regenerate local tissues in selected head and neck functional
disorders.
34.3.4 Vocal Folds
Vocal fold scarring is the cause of severe dysphonia and
phono-asthenia and represents a therapeutic challenge. The
ideal surgical solution should concurrently provide vocal
fold augmentation and re-establishment of tissue elasticity.
Patients affected by severe dysphonia related to extensive
vocal fold scarring due to previous oncological surgery, with
glottal insufciency, phono-asthenia and a gap no greater
than 3mm caused by unilateral vocal fold paralysis or vocal
fold atrophy, represent ideal candidates to fat grafting. The
procedure requires general anesthesia and injection have to
be performed via direct microlaryngoscopy using a transoral
approach. The adipose tissue is harvested as conventional
procedure and then processed as decantation technique for
obtaining microfat for vocal fold augmentation. Traditional
fat grafting is then combined to nanofat (processed by using
Tulip’s TRUE NanoFat System (TNF™) to promote tissue
pliability restoration and remodeling scars thanks to the high
concentration of viable regenerative cells. Processed microfat and nanofat micro-aliquots, further reduced by a sizing
transfer 1.2mm, are to be placed in the vocal fold and paraglottic space in multiple tunnels to enhance graft neovascularization. We inject with 27G and 30G needles connected to
a Luer-lock system syringe for phonosurgery.
Regenerative surgery by using adipose fat grafting
improves the voice quality and the perceived swallowing
capability. Postoperative objective videolaryngostroboscopic
evaluation analyzed voice handicap index (VHI) and maxi-
34.3.5 Immediate Postintervention Situation
Facial lipostructure presents a low complication rate and a
short hospitalization time (one-day surgery procedure).
There were no signicant surgical complications, either
from the fat donor sites or the reconstructed areas. Short lasting mild edema, facial ecchymosis, and bruising are frequent
and these conditions are spontaneously resolved within
2weeks. Compression dressing is applied on the donor site
for 1week and then compressive garments for at least one
month. Heparan sulfate ointment is indicated to reduce
ecchymosis in the donor sites. Major or persistent complications such as a vascular occlusion phenomenon, nervous
injuries infections, fat cysts, and liponecrosis are uncommon. Fat embolism syndrome and acute pulmonary embolism from deep vein thrombosis present a low risk considering
the small caliber of the blunt cannula used for lipoaspiration,
the proper prophylactic therapy, and fast mobilization. No
local or systemic infectious complications related to the procedure were recorded. Patients can require a second procedure. Antibiotic therapy (Amoxicillin) is administered for
5days.
The easy procedure, the low invasiveness, and the short
learning curve are the key points of the facial lipostructure. Volume improvement and facial reshaping, with a
customized and natural look outcome of the fat grafting,
is the goal of the treatment of the craniofacial
malformations.
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Fig. 34.3 Fat grafting in systemic sclerosis (xerostomia), with evident
perilabial brosis and difcult mouth opening. Preoperative, intraoperative, and immediate/long-term postoperative view. Signicant
improvement in mouth opening capacity 6months after autologous fat
transfer (8cc)
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Irregularities can be observed when fat is injected too
supercially or in an area with thin skin.
Regenerative capacity is the winning card in systemic
autoimmune connective tissue disease. In these cases, skin
elasticity and local vascularization can improve and thanks
to the benecial effects of the combined use of autologous
fat graft and platelet-rich plasma (PRP).
A second step of fat graft usually is required to optimize the
prole defect. The reason for a further surgical fat injection
could be underestimation of the required soft tissue volume,
high unpredictable resorption rate of the grafted fat, or inadequate recipient site, especially in cases of scars, burns, or autoimmune brosis. In clinical practice, surgical procedures
designed to augment soft tissues are the most commonly performed after orthognathic surgery and reconstructive surgery,
and fat graft seems to be a reliable option to produce a more
natural result for correction of maxillomandibular asymmetry
and other cranio-facial sequelae (Fig.34.4). It allows the surgeon the opportunity to sequentially ne-tune and rene the
nal contours and volume of the facial soft tissue, respecting the
proper anatomy of facial subunity resulting in improved facial
symmetry. Improvement of skin quality of the treated region is
generally observed a few months after fat grafting. Regarding
facial contouring, we consider that injection respecting aesthetic
facial subunits anatomy is the key point for a successful outcome. Further, every anatomic facial area presents a different
rate of fat integration with native tissues, as the malar and lateral
cheek regions seem to be highly favorable for fat grafting, in
comparison to the upper and lower lips subunits.
34.3.6 Late Postintervention Situation
Data and parameters must be collected for every patient:
demographic data, clinical data, the number of surgical sessions, the total and average amount of harvested/injected fat,
and preoperative and postoperative imaging and photographs. These features are signicant to evaluate postoperative outcomes, complications, reabsorption, eventual need to
optimize result with other type of surgery. The nal assessment of the fat grafting will be performed at least 6months
after surgery, when adipose tissue transplant can be considered as stable.
For clinical follow-up, 3D photographic reports and MRI
are suggested. In functional disorders, specic evaluation is
needed to assess clinical outcomes.
Autologous adipose tissue graft is a well-established
method with several clinical applications in plastic surgery
and nds increasing application in head and neck surgery.
The autologous adipose tissue has the main advantage of
being completely biocompatible and easily available, also in
pediatric patients or in severe autoimmune disease, without
morbidity for the donor site and without signicant additional costs for the operating room.
Adipose tissue can be safety used to restore volumetric
soft tissue decit in congenital cranio-facial malformations,
post traumatic/iatrogenic or post oncological facial asymmetries, and burn disgurements, as well as to promote skin
regeneration and quality improvement in radio dermatitis,
burning scars, systemic autoimmune connective tissue dis-
ac
bd
Fig. 34.4 Fat grafting in posttraumatic case. (a) Preoperative view of
right forehead posttraumatic depression and contour irregularities. (b)
Preoperative view of posttraumatic retracting left upper lid and lagophtalmos. (c) 2years post op after one session of fat grafting (right fore-
head depression). (d) 1year post op after full thickness skin graft and
consecutive 2cc of fat grafting for left upper lid. (e) Intraoperative planning of fat graft
e
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eases or functional disorders as velopharyngeal incompetence or vocal folds paralysis.
Despite the well-known clinical advantages of the autologous fat graft, the main limit remains the unpredictable viability of transferred fat. Several studies showed greater tissue
Questions
First Block
[Question 1] What are the main advantages of autologous fat
grating?
[Question 2] Which is the main downside of autologous fat
grating?
[Question 3] What are the main goals of lipolling after
oncologic demolition in head & neck?
[Question 4] Is fat grafting associated to and increased risk
for oncologic recurrence?
viability and a lower percentage of contaminants in fat tissue
washed and ltrated within a closed system. Fat grafting is
suitable and can improve the quality of life in patient treated
for head and neck diseases, due to the possible benets in
mobility, aesthetic outcomes, and skin quality.
The autologous fat is readily available and inexpensive to harvest, it
is “self” and therefore lacks a host immune response, it is safe and
noncarcinogenic and it is acquired with a minimally invasive
procedure
It is the variability of results, particularly in terms of fat absorption
rate (25–90% after 6months), hardly to estimate due to the
subjectivity of the quantication methods
The main objective of fat injection in post-oncologic patients is to
improve skin quality (elasticity, vascularization) and secondly to
restore volume loss. Usually is possible to achieved an improvement
in the quality of irradiated skin
The theoretical risk associated with the injection of adipose-derived
stem cells into a post-oncologic tissue bed has not been conrmed by
the research conducted so far; hence, this reconstructive approach,
under the proper indication, can be offered to patients previously
treated for malignancy
Second Block
[Question 1] What is the role of lipolling in cleft lip and
palate sequelae?
[Question 2] When is dedicated to treat velopharyngeal
incompetence with lipolling?
[Question 3] Why fat grafting is so useful for treating
systemic sclerosis?
[Question 4] Among all of the patients affected by
dysphonia, which represent the ideal
candidates to fat grafting therapy?
Third Block
[Question 1] Regarding facial contouring, what should be keep
in mind to achieve a satisfactory result?
[Question 2] What are the main applications of lipolling in
head and neck?
[Question 3] What are the methods to quantify the results? 3D photographic reports and MRI
[Question 4] Why seems to be wise processing the harvested
tissue before the reinjection?
Cleft lip sequelae: autologous fat grafting can improve scarring and
increase upper lip volume. Cleft palate sequelae: autologous fat graft
is an optimal option for velopharyngeal incompetence
Mild and moderate cases. The augmentation of the lateral and
posterior pharyngeal walls (named Passavant’s crest) with autologous
fat graft can be sufcient to compensate mild cases of velopharyngeal
incompetence
Because lipolling carry both lling effect and regenerative potentials
due to their adipose-derived stem cells (ASCs) content
Patients affected by severe dysphonia, related to extensive vocal fold
scarring due to previous oncological surgery, with glottal
insufciency, phono-asthenia and a gap no greater than 3mm caused
by unilateral vocal fold paralysis or vocal fold atrophy
We believe that the key point for a successful outcome is that
injections respect aesthetic facial subunits anatomy
Adipose tissue can be safety used to restore volumetric soft tissue
decit in congenital cranio-facial malformations, posttraumatic/
iatrogenic or post oncological facial asymmetries, and burn
disgurements, as well as to promote skin regeneration and quality
improvement in radio dermatitis, burning scars, systemic autoimmune
connective tissue diseases or functional disorders as velopharyngeal
incompetence or vocal folds paralysis
Several studies showed greater tissue viability and a lower percentage
of contaminants in fat tissue washed and ltrated within a closed
system
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Acknowledgments The authors would like to thank dr. Federico
Giorgini for his collaboration in the drafting of the chapter.
Conicts of Interest The authors declare that there are no conicts of
interest regarding the publication of this paper.
Data AvailabilityThe data used to support the ndings of this study
are available from the corresponding author upon request.
References
1. Clauser LC, Tieghi R, Galiè M, Carinci F. Structural fat grafting:
facial volumetric restoration in complex reconstructive surgery. J
Craniofac Surg. 2011;22(5):1695–701.
2. Mazzola RF, Cantarella G, Torretta S, Sbarbati A, Lazzari L,
Pignataro L.Autologous fat injection to face and neck: from soft tissue augmentation to regenerative medicine. Acta Otorhinolaryngol
Ital. 2011;31(2):59–69.
3. Coleman SR.Structural fat grafting: more than a permanent ller.
Plast Reconstr Surg. 2006;118(3, supplement):108S–20S.
4. Khouri RK, Rigotti G, Cardoso E, Biggs TM.Megavolume autologous fat transfer: part I.Theory and principles. Plast Reconstr Surg.
2014;133:550–7.
5. Tonnard P, Verpaele A, Peeters G, Hamdi M, Cornelissen M,
Declercq H.Nanofat grafting: basic research and clinical applications. Plast Reconstr Surg. 2013;132(4):1017–26.
Reverse Expansion Technique forBreast
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Reconstruction After Skin-Sparing
35
andNipple-Sparing Mastectomy
CiprianiRiccardo, PintoValentina, andFabiocchiLuca
Contents
35.1 Surgical Technique 465
35.2 Key Points of the Procedure 467
35.3 Immediate Postintervention Situation 468
35.4 Late Postintervention Situation 470
References 472
In the past 30 years, autologous fat grafting has increased its
application both in the aesthetic and reconstructive
procedure.
Although autologous fat grafting in the context of breast
reconstructive surgery is mainly related to surgical revisions
of breast reconstructions with prostheses or autologous aps,
or for renements, in this chapter we present a peculiar
breast reconstruction technique based exclusively on adipose
tissue transplantation, without prostheses or autologous
aps.
Fat grafting as ancillary technique for prosthetic or apbased reconstructions allows improvement in esthetic results
and optimizes natural look result both in terms of breast
shape and touch. Further advantage is the reduction of adipose storage in nonesthetic places reporting greater patients’
satisfaction. The proposed autologous technique for breast
reconstruction, so-called “reverse expansion,” consists of a
lipostructure multisteps procedure after a breast expander
insertion and ination, using an exclusive fat tissue transplantation (lipostructure) and a progressive breast expander
deation [1].
C. Riccardo · P. Valentina (*)
Plastic Surgery, IRCCS Azienda Ospedaliero-Universitaria di
Bologna, Bologna, Italy
F. Luca
Plastic Surgery, Azienda Ospedaliero Universitaria, Modena, Italy
e-mail: luca@fabiocchi.it
35.1 Surgical Technique
“Reverse expansion” represents a current autologous breast
reconstruction requiring the combined use of a skin expander
and multiple lipolling sessions [1].
The rst step is the traditional placement of a breast tissue
expander under the major pectoral muscle at the time of the
skin sparing (SS) mactectomy or nipple skin sparing (NSS)
mactectomy because of breast cancer. After a minimum period
of 6 months from mastectomy, autologous breast reconstruction can start with a progressive deation of the expander and
a gradual fat grafting in the obtained breast pocket (Fig.35.1).
The procedure is usually performed under general anesthesia; adipose graft can be harvested by using a traditional
blunt liposuction cannula (2.5 mm); and a previous tissue
inltration is by using adrenaline 1mg in 1000cc of saline
solution. Fat tissue is harvested from common fat donor sites
such as the abdomen, gluteus, hips, and lumbar region.
Harvested fat is collected in 50-mL syringes through the
Lipokit machine® (Medikan Ltd, Kangnam, South Korea),
which allows suction and then centrifugation. The centrifugation lasts for 3min at 4000rpm. The proper lter of this
kind of syringes allows to completely separate the oily component form the adipose tissue in a closed circuit, avoiding
air contact.
The puried adipose tissue is then injected in the recipient
site by using 3 mL syringes and a Coleman cannula
(Table 35.1).
© 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_35
465
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