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C. Riccardo et al.
a
c
b
d
Fig. 35.1 “Reverse expansion” total breast reconstruction in monolateral left NSS mastectomy. Two sessions of fat grafting (mean grafted
volume for each session: 307.5 cc). (a) Preoperative view. (b)
Postoperative rst session of fat grafting; skin expander still inside
At the beginning of every surgical session, once the
amount of fat graft to be harvested and injected is determined, the skin expander is deated, by removing a similar
volume of saline solution. Thanks to this approach, the fat
graft has the chance to root without pressure, while simultaneously, the partially deated skin expander helps in keeping
the skin straight and the breast reconstruction stable over the
time.
For each surgical step, an average of 300cc of fat graft is
usually injected, being able to reach a maximum of 480cc.
Complete breast with reverse expansion cannot be performed
in one surgical session; it needs about 3 or 4 surgical steps (4
for breast underwent to previous radiotherapy).
The external appearance of “orange peel skin” will be
indicative of excessive interstitial pressure and will require
interruption of the procedure. According to these advices, it
gradually deated. (c) 2 years post-op second session after skin
expander removal and further fat graft in the left breast and contralateral mastopexy. (d) Stable symmetry and natural texture and elasticity
after 2years from the nal session
is possible to obtain a complete breast with about 3 lipostructure sessions, removing the tissue expander during the last
step. Needling and Rigottomies are useful to release scar tissues; drains or removal of the capsular envelope are not
needed: the capsular layers collapsing are functional to the
denition of a natural breast ptosis.
Of course, the number of sessions will depend on the volume of the harvested fat, the volume of the injected fat tissue,
the volume of the breast to be reconstructed, and the elastic
potentials of pre-radiotreated skin. Therefore, the previously
irradiated patients require a higher number of sessions as
their breast tissues are less expandable than the normal ones.
The average volume of transplanted fat, higher in the
radiotreated patients, is better explained if we consider that
the percentage of living fat graft is lower when it is compressed by any sort of pressure. A rigid, nonelastic,
35 Reverse Expansion Technique forBreast Reconstruction After Skin-Sparing andNipple-Sparing Mastectomy
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Table 35.1 “Reverse expansion” for breast reconstruction: sequential
steps in fat graft harvesting, processing, and injection
“Reverse expansion” surgical procedure
1 Skin incision with a 11 blade (peripheral area of the donor site)
2 Injection of adrenaline/saline solution (1mg/1000cc SS) in the
selected area
3 Waiting 10min
4 Harvesting fat tissue in the selected area by using a 2.5mm
blunt cannula with multiple elliptical holes, connected with a
50cc Luer Lock FPU (fat processing unit) single-use syringe
(Lipokit machine® kit—Medikan Ltd., Kangman, South Korea)
5 3min—4000rpm fat graft centrifugation
6 Injection of the processed fat tissue to reconstruct breast using
3mL single-use syringes (about 300cc/surgical session)
radiotreated skin with poor blood supply may cause higher
fat loss than a normal one, and therefore, to achieve the same
amount of living fat, a higher volume needs to be injected.
During the last lipostructure session, the skin expander is
removed, thus accomplishing a complete breast reconstruction using autologous tissue alone without requiring the use
of implants or autologous aps. In the same surgery, contralateral breast modeling (mammary reduction/mastopexy)
and, when possible, nipple reconstruction can be performed.
The minimum time between two consecutive surgical steps
has to be about 4months.
35.2 Key Points oftheProcedure
Key points of the “Reverse expansion” procedure are the
real factors limiting the engraftment of adipose tissue and its
viability. It is important at this point to clarify that when adipose tissue is transplanted into subcutaneous recipient, the
interstitial pressure is automatically increased. When, following the progressive adipose graft, this pressure exceeds
the diffusion pressure of the capillaries of 16mmHg, there
will be no more engraftment because neoangiogenesis has
not yet occurred and the transplanted fat will no longer
receive nourishment. Therefore, one of the main factors limiting engraftment is precisely the capillary diffusion pres-
sure. The rational of this concept is that fat centrifugation on
dened parameters (3 min at 4000 rpm), modied than
Coleman technique, allows to obtain a drier adipose tissue,
with a lower aqueous component, avoiding to stress excessively the adipocytes and promoting their viability. This
strategy leads to graft a greater amount of adipose tissue
before reaching the limit of the interstitial pressure of the
16 mmHg, value that acts as a biological factor limiting
engraftment. For this purpose, the breast tissue expander
plays a key role; according to basic notions of the plastic
surgery, an expanded tissue develops a richer vascular network, showing itself more elastic and compliant. These features, then, allow a greater amount of fat grafting in the
expanded recipient site before interstitial pressure increases
over the engraftment limit of 16mmHg.
A further factor determining effective engraftment is the
fat injection technique; the favorite procedure provides fat
transplantation using a retrograde injection (0.1mL/lipoaspirate for step) by using 3mL syringes, connected to blunt cannula with 1.5–2 mm caliber. Grafted fat must be
homogeneously distributed in all the breast area to be reconstructed. This allows not only a better esthetic result but also
a great reduction of complications (Fig.35.2).
The goal is to obtain a three-dimensional network of viable adipocytes that will receive more nourishment, reducing
the necrosis areas and the risk of reabsorption and oily cists.
The periprosthetic capsule can work as an excellent guide
for the transplantation of the fat graft.
1. [Question 1] What is the
“Reverse
expansion”
technique for
breast
reconstruction?
2. [Question 2] How many
surgical sessions
need to complete
breast
reconstruction?
3. [Question 3] What are the
biological key
points of the
procedure?
4. [Question 4] What is the
favorite fat
injection
technique of fat
grafting?
“Reverse expansion” represents a
current autologous breast
reconstruction technique
requiring the combined use of a
skin expander and multiple
lipolling sessions
Complete breast with reverse
expansion cannot be performed in
one surgical session; it needs
about 3 or 4 surgical steps (4 for
breast underwent to previous
radiotherapy)
One of the main factors limiting
engraftment is precisely the
capillary diffusion pressure. The
rational of this concept is that fat
centrifugation on dened
parameters (3min at 4000rpm),
modied than Coleman
technique, allows to obtain a drier
adipose tissue, with a lower
aqueous component, avoiding to
stress excessively the adipocytes
and promoting their viability.
This strategy leads to graft a
greater amount of adipose tissue
before reaching the limit of the
interstitial pressure of the
16mmHg, value that acts as a
biological factor limiting
engraftment
The favorite fat injection
procedure provides fat
transplantation using a retrograde
injection (0.1mL/lipoaspirate for
step) by using 3mL syringes,
connected to blunt cannula with
1.5–2mm caliber
468
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Fig. 35.2 “Reverse expansion” total breast reconstruction in monolateral right NSS mastectomy. Two sessions of fat grafting (mean grafted
volume for each session: 370 cc). (a) Preoperative view. (b)
Postoperative rst session of fat grafting; skin expander still inside
35.3 Immediate Postintervention Situation
gradually deated. (c) 2 years post-op second session after skin
expander removal and further fat graft in the left breast without contralateral surgery. (d) Stable symmetry and natural texture and elasticity
after 2years from the nal session
operative week. Major complications such as fat embolism
syndrome and acute pulmonary embolism from deep vein
35.3.1 Advantages
thrombosis present a low risk considering the small caliber
of the blunt cannula used for lipoaspiration, the proper pro-
The “Reverse expansion,” as all the lipostructures tech-
niques, presents a low complication rate and a short hospitalization time (1-day surgery procedure). No hematomas,
infections, vascular, or nervous injuries were reported in the
treated patient. No signicant further surgical complications
either from the donor site or the injected site were reported.
Mild edema and bruising were frequent during the rst post-
phylactic therapy, and fast mobilization. Other advantages
are an easy learning curve compared to other breast reconstruction methods with autologous tissue, a natural and soft
texture breast look, a remodeling of the silhouette following
liposuction and the scars lackness, and otherwise present in
the donor areas in the classic breast reconstruction with
autologous tissue.
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Volume improvement and the mechanical effect of the fat
graft can be immediately seen, while improvement of skin
quality of the reconstructed breast is generally observed a few
months after fat grafting (Fig.35.3, 35.4). Compression dressing is applied on the donor site for 1week and then compressive garments for at least 1 month. Antibiotic therapy
(Amoxicillin) is administered for 5days. Heparan sulfate ointment is indicated to reduce ecchymosis in the donor sites.
The long time and the multisteps procedure to complete
breast reconstruction are the main disadvantages of this
autologous technique. Further, the absence of fat tissue to be
harvested is a major limitation to complete breast reconstruction in thin patients. In these cases, and after a surgical evaluation, patients can be treated with a combined approach
using implants and fat grafting or autologous aps.
Autologous fat tissue is the ideal ller, which is readily
available and biocompatible. It has no major rejection risks
in the recipient site, and furthermore, it is affordable. It can
be easily harvested from many storage sites by simply using
a liposuction cannula. Further, lipostructure allows body
reshaping through the elimination of any possible nonesthetic fatty donor sites [2].
The rst techniques using fat tissue in plastic surgery for
breast reconstruction and body reshaping were introduced
about one century ago. The rst surgeon to use these procedures was Gustav Neuber in 1893, when he described the use
of a forearm lipoma to correct face defects after tuberculosis.
The autologous fat tissue transplantation progressively
improved as a technique by the introduction of liposuction,
described by Fisher in 1974.
In the literature, the risk of cancer relapse stimulation
after lipolling has been much debated in the past few years
because of the presence of growth factors in the recipient site
[3]. In 2012, Petit etal. published a study based on a group
of patients who underwent lipolling after mastectomy
because of an intraepithelial neoplasm [4]. Petit hypothesized an augmented risk of cancer relapse in these patients.
Few months later, because of the small sample of patients, to
its extreme dishomogeneity, and to a sometimes ineffective
preoperative stadiation, Petit himself admitted that it was not
possible to reach any denite conclusion on the basis of the
sole available data. Recently, Waked etal. published a metaanalysis considering a large number of papers concerning
lipolling. Despite a broad number of possible pro- oncogenic
adipokines in a lipolling recipient site, no clinical study has
pointed out a signicant increase in cancer relapse risk.
Detractors of the lipolling technique criticise this method
because of the extreme variability in fat tissue survival.
Despite many proposed techniques, it is currently unclear
which is the most effective.
Many papers that describe many possible collections, processing, and injection techniques exist in the literature. The
ab
de
Fig. 35.3 “Reverse expansion” total breast reconstruction in bilateral
NSS mastectomy. Three sessions of fat grafting (mean grafted volume
for each session: 340cc/right–324cc/left). (a) Pre-operative view. (b)
Post-operative rst session of bilateral fat grafting; skin expander still
inside gradually deated. (c) Post-op second session after skin expander
removal and further bilateral fat grafting. (d) 1year post-op third session of bilateral fat grafting. (e) Stable symmetry and natural texture
and elasticity after 1year from third fat grafting
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reverse expansion technique has been described in 2016 by
Stillaert etal. in seven cases [5], and later, Fabiocchi etal. [1]
presented their experience with the procedure in their cohort
of patients. At present, it has been demonstrated how fat tissue survival percentage does not depend on the collection
technique. Despite this, it is surprising how the management
of the recipient site has never been considered as a study
point to improve the percentages of surviving fat tissue.
Compression removal over the implanted fat in the recipient
site, which means pre-expansion, allows signicant growth
of the living fat tissue volume, improving the so-called
grafto-capacity ratio. Some authors performed the mammary
pre-expansion of the recipient tissue using the BRAVA system, which is applied after mastectomy 10 h a day, for
4weeks. Pre-expansion allows for an ischemic reduction and
then a percentage increase of living fat tissue. Then, through
pre-expansion, a neo-angiogenesis stimulation is possible,
followed by a better and faster revascularization of the
grafted fat.
Reverse expansion allows to achieve the same neoangiogenic effects and increase of living fat using an implanted
breast expander as well. The recipient site preparation, in
fact, may be performed through a standard breast expander
implant after mastectomy, which is much more comfortable
and easier to manage for the patient in comparison with any
external instrument such as BRAVA. Moreover, a breast
expander stretches the skin faster than BRAVA, allowing
ample reconstructions in a shorter time. Our mean grafted fat
volume was 304.9 mL. Khouri et al. reported an average
grafted fat volume of 225mL.
1. [Question 1] Which are the
most common
complications
after a surgery for
“Reverse
expansion”?
2. [Question 2] How long is the
hospitalization
after a surgery for
“reverse
expansion”?
3. [Question 3] What does the
postoperative care
include?
4. [Question 4] Is fat grafting
dangerous in
post-oncologic
tissues?
The “Reverse expansion”
presents a low complication
rate. Mild edema and bruising
are the most common minor
complications during the rst
postoperative week
The hospitalization time is very
short (usually day surgery/1 day
surgery)
Fast mobilization and proper
prophylactic. Antibiotic therapy
(Amoxicillin) for 5days.
Heparan sulfate ointment is
indicated to reduce ecchymosis
in the donor sites
This specic aspect is very
important and still under
evaluation. So far, no evidence
of an increased recurrence of
malignancy has been reported
in large data studies. It is
accepted by the scientic
community that fat grafting is
safe after oncologic demolition
35.4 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. These features
are important to evaluate postoperative outcomes, complications, reabsorption, and eventual recurrence.
The nal assessment of the fat grafting will be performed
at least 6months after the last surgical step, when adipose
tissue transplant can be considered as stable.
In selected cases, the clinical results of this autologous
breast reconstruction are comparable to those obtained with
other autologous procedures, which are performed more
often, such as the DIEP aps. Breasts reconstructed by
“Reverse expansion” procedure are completely made up of
adipose tissue, and this condition led to a volumetric modication following patient’s weight changes just like a natural
breast.
For clinical follow-up, we suggest an annual mammographic and ultrasound assessment; some patients underwent
to reverse expansion can develop dystrophic microcalcications in the grafted fat tissue, which required a stricter ultrasound follow-up, leaving MRI and biopsies for unclear cases,
as for any breast cancer patient’s follow-up.
Several procedures have been described for complete
autologous breast reconstruction over the years. DIEP ap is
nowadays considered the gold standard, but is not always
possible to perform it, due to the need for microsurgical
skills and specic instruments, a long learning-curve, the
ideal patients, and their compliance. The fat grafting combined to reverse breast expansion is considered a safe, simple, and not invasive procedure, not requiring a peculiar
learning curve, ensuring a fast postoperative recovery with
excellent and stable results.
Thanks to these favorable features, our approach consisting of the “reverse expansion” is the preferred surgical option
for an autologous complete breast reconstruction and it represents a viable alternative to microsurgical DIEP ap to
obtain a natural breast shaping, avoiding major
complications.
Although our clinical results are encouraging, “reverse
expansion” still needs an optimization of the procedure to
ensure greater long-term fat graft viability and a higher follow- up, necessary to evaluate both esthetic results and longterm oncologic safety (Figs.35.5 and 35.6).
1. [Question 1] When the result
obtained with the
reverse expansion
can be considered
stable?
There is an individual
variability, but generally
after 6months the result
is denitive
ab
cd
35 Reverse Expansion Technique forBreast Reconstruction After Skin-Sparing andNipple-Sparing Mastectomy
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2. [Question 2] What is the
evolution of breast
reconstruction over
the years?
3. [Question 3] What is the proper
follow-up after
reverse expansion?
Breasts reconstructed by
“Reverse expansion” are
composed by adipose
tissue and undergo
volumetric modication
following patient’s
weight changes
Mammographic and
ultrasound assessment
every year
4. [Question 4] What are the main
upside of reverse
expansion?
It is a safe, simple, and
not invasive procedure. It
does not require a
peculiar learning curve.
Fast postoperative
recovery. Stable and
pleasant results
Fig. 35.4 “Reverse expansion” total breast reconstruction in right SS
mastectomy. Two sessions of fat grafting (mean grafted volume for
each session: 320cc). (a) Preoperative view. (b) Postoperative rst session of fat grafting; skin expander still inside gradually deated. (c)
2years post-op second session after skin expander removal and further
fat graft, NAC reconstruction, and contralateral mammary reduction.
(d) Stable symmetry and natural texture and elasticity after 2 years
from completing reconstruction
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C. Riccardo et al.
Fig. 35.5 “Reverse expansion” total breast reconstruction in left SS
mastectomy. Three sessions of fat grafting (mean grafted volume for
each session: 329cc). (a) Preoperative view. (b) Postoperative rst session of left fat grafting and contralateral mastopexy; skin expander still
Fig. 35.6 Breast MRI after
total right breast
reconstruction by “reverse
expansion”. Imaging shows us
the exclusive adipose
component of the
reconstructed breast
Data Availability The data used to support the ndings of this study
are available from the corresponding author upon request.
Conicts of Interest The authors declare that there are no conicts of
interest regarding the publication of this paper.
References
1. Fabiocchi L, Semprini G, Cattin F, Dellachiesa L, Fogacci T, Frisoni
G, Samorani D. Reverse expansion: a new technique of breast
reconstruction with autologous tissue. J Plast Reconstr Aesthet
Surg. 2017;70(11):1537–42.
inside gradually deated. (c) Post-op second session after skin expander
removal and further fat grafting. (d) 2years post-op third session of left
fat grafting and NAC reconstruction. (e) Stable symmetry and natural
texture and elasticity after 2years from third fat grafting
2. Illouz YG, Sterodimas A. Autologous fat transplantation to the
breast: a personal technique with 25 years of experience. Aesthet
Plast Surg. 2009;33:706–15.
3. Waked K, Colle J, Doornaert M, Cocquyt V, Blondeel P.Systematic
review: the oncological safety of adipose fat transfer after breast
cancer surgery. Breast. 2017;31:128–36.
4. Petit JY, Botteri E, Lohsiriwat V, et al. Locoregional recurrence risk after lipolling in breast cancer patients. Ann Oncol.
2012;23(3):582–8.
5. Stillaert FB, Sommeling C, D’Arpa S, etal. Intratissular expansionmediated, serial fat grafting: a step-by-step working algorithm to
achieve 3D biological harmony in autologous breast reconstruction.
J Plast Reconstr Aesthet Surg. 2016;69(12):1579–87.
Simultaneous Body Liposuction
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andBreast Remodelling by Fat
D.Fasano, G.Gasparini, andG.Fasano
Contents
36.1 Introduction 473
36.2 Personal Approach 474
36.3 Personal Technique (Table 36.1) 475
36.4 Results 476
References 480
36
36.1 Introduction
Since the introduction in the early 1980s by Illouz [1, 2] and
Fournier [3], liposuction has become one of the most performed procedures in plastic surgery, permitting in many
cases impressive remodeling of the trunk and limbs.
Soon after, the idea of reintroducing part of the lipoaspirate was developed to correct unfavourable results of liposuction [3, 4] and defects of the face [5]. The idea of fat
grafting was not new at that time but had been previously
nearly abandoned because of the inconsistent long-term
results [6].
The possibility to obtain easily and readily an abundant
quantity of fat was very attractive and stimulated a raised
interest in fat grafting with an increased use to accomplish
various reconstructive and aesthetic objectives. The regenerative potential of autologous fat transfer was then demonstrated by the successful treatment of radiation tissue
damages, scars, and ulcers [7–10].
Concerning the breast, the use of fat grafting was initially
forbidden by the ASPS in 1987 because of issues related to
safety and efcacy.
D. Fasano (*)
Plastic Surgeon, Private Practice, Bologna, Italy
e-mail: daniele.fasano@fastwebnet.it
G. Gasparini
Plastic Surgeon, Private Practice, Parma, Italy
G. Fasano
Resident Plastic Surgeon, University of Siena, Siena, Italy
The introduction of a rigorous systematic technique of fat
harvesting, preparation, and reintroduction by Coleman,
dened as “lipostructure”, has led to positive results for the
face and body [11, 12]. Based on this favourable experience,
Coleman decided to perform fat grafting to the breast reporting his results in 2007 [13]. In the same year, the ASPS Fat
Graft Task Force was created to assess the efcacy and safety
of lipolling in breast surgery and establish evidence-based
recommendations to promote its use. The Task Force conclusion was favourable and the moratorium condemning the
procedure was reversed. In 2009, the ASPS Fat Graft Task
Force stated that “Fat grafting may be considered for breast
augmentation and correction of defects associated with medical conditions and previous breast surgeries; however,
results are dependent on technique and surgeon expertise”
[14].
Concern about radiologic sequelae and surveillance
radiologic difculties after lipolling has been solved by the
distinction between suspicious ne, linear and pleomorphic
microcalcications and macrocalcications related to fat
necrosis as observed after fat transfer [15, 16].
Fat transfer to the breast has been more and more frequently performed with many now well-established indications in both aesthetic and reconstructive surgery, leading to
an important changing in the way of performing breast
surgery.
Actual indications include breast augmentation, improvement of results of breast augmentation with a prosthesis,
replacement of implants, treatment of tuberous breast, cor-
© 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_36
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rection of lumpectomy and radiotherapy, breast reconstruction after mastectomy [13, 17–19].
We have personally veried in our experience that lipomodeling improves the volume, shape, projection, feel, and
silhouette of the breast.
Because of this, we have been attracted by the possibility of
improving other different and peculiar breast defects, in particular when an important remodeling of the lower limbs and the
trunk was required. The simultaneous treatment of defects in
different areas of the body taking advantage of what is removed
to improve one area without discharging it by injecting into
another decient area is one of the fundamental principles of
plastic surgery (the Robin Hood principle of Millard). The contemporary presence of some adiposities requiring liposuction
and of a breast defect is a perfect indication.
Breast asymmetry, augmented intermammary distance,
Poland syndrome, pectus excavatum are some peculiar conditions that can be successfully treated by fat grafting above
all when liposuction is indicated.
36.1.1 Asymmetric Breasts
Asymmetric breasts are a real challenge for the plastic surgeon, in particular when one breast has a good fullness and a
nice shape, while the other is hypoplastic, stenotic, or morphologically unsatisfactory. Traditionally, an implant is
inserted in the underdeveloped breast. Often, but not always,
the initial result is satisfactory, but, with time, asymmetry of
shape and volume becomes evident.
In these cases, lipomodeling can yield a breast very similar to the contralateral, with stable results and a maintained
symmetry, with particular evidence of ptosis and volumetric
changes due to weight variations. Depending on the degree
of asymmetry and hypoplasia, one or more fat transfer sessions will be needed for an optimal result.
36.1.2 Reduction oftheIntermammary
Distance
Lipomodeling appears to be very useful in these cases, if an
adequate quantity of fat is available, obtaining a satisfactory
reconstruction of the anterior axillary pillar simulating the
lateral border of the pectoralis major and an appropriate and
stable breast volume. Often repeated procedures, every 3 or
4 months, are necessary to achieve a satisfactory result. The
advantages of the technique are that the procedures are simple, leading to an improvement of the donor sites in the correct indications, avoiding the unfavourable side effects of
aps and implants. Lipomodeling can revolutionize the management of Poland syndrome [22, 23].
36.1.4 Pectus Excavatum
Pectus excavatum is a complex deformity involving hollowing of the anterior sternocostal wall. It usually has little or no
functional impact and, in most cases, the problem is essentially morphologic and aesthetic, with considerable deformity of the bust if the condition is very marked or lateral.
Custom-made silicone implants were traditionally used to
correct the deformity with a high risk of extrusion.
Fat transfer is an additional tool with many advantages. It
can provide a satisfactory one-stage correction in cases of
mild deformity; in cases of more severe defects, multiple
procedures are necessary if adequate donor sites are available [19].
36.1.5 Mastopexy
The satisfactory experience of fat transfer in many difcult
cases of breast plastic surgery has yielded frequent use in
mastopexy. It can be an excellent option to provide upper
pole fullness if enough fat is available and the patient does
not require a signicant augmentation, maintaining a natural
breast. The breast is shaped by the mastopexy and fat grafting helps create a natural transition from the chest wall to the
upper pole of the breast [24].
In cases of augmented intermammary distance or medial
breast asymmetry, fat transfer can be very useful both as a
complement of an augmentation mammaplasty with implants
and as a unique procedure to reduce the intramammary distance and improve the “dècolleté”. This specic condition
can be corrected uniquely by this approach [20, 21].
36.1.3 Poland Syndrome
The treatment of Poland syndrome remains a challenge to
the plastic surgeon. The traditional treatment consists of
combining a latissimus dorsi ap with an implant.
36.2 Personal Approach
Fat transfer has changed the modern approach to breast surgery, permitting remarkable results with minimal scar.
However, there are still some unclear aspects in the behavior of fat transfer concerning the retention rate. In a systematic review of volume retention after autologous fat grafting
in cosmetic breast augmentation referred to eight articles,
average volume retention of 62.4% after a mean follow-up of
16.6months [25].
Volume retention rates after fat transfer to the breast vary
according to different techniques and methods used for evaluation, ranging from 37 [26] to 65% [27].
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This uncertain behavior has been conrmed by our experience. Believing that actually it is difcult to augment the
volume of the breast with fat in one shot in a way comparable
to the implants, and several procedures can be eventually
required. Then, the variable decrease in volume is to be considered in the rst 3 or 4 months, leading to a quite unpredictable nal result.
Of consequence, the woman can be disappointed by the
augmentation achieved even if an evident improvement of
other areas of the body is obtained by liposuction. For this
reason, we do not actually suggest fat transfer to achieve just
a breast augmentation.
On the contrary, in our experience, the most effective and
predictable results are obtained in the presence of volumetric
asymmetries, malformations, and morphologic anomalies,
when the primary goal is not the volumetric increase. An
adequate improvement of shape is much more consistently
reached than an important augmentation, above all in one
step.
The satisfaction rate in these cases is high, above all if
adiposities are present in other areas and are likely to be well
improved by liposuction. For these reasons, attention has
been focused particularly on these problems.
In any case, we try to preserve an additional donor site for
a subsequent procedure, such an adiposity considered minor
from the patient or the posterior lumbar area that can be very
useful as secondary donor site.
36.3 Personal Technique (Table 36.1)
The preferred indication for fat transfer to the breast is when
a patient, with an indication of body recontouring and liposuction, requires breast remodeling. It was believed that in
these cases the patients are satised combining the correction of two or more morphologic defects, and the surgeon
takes advantage of one of the best principles of plastic surgery by using expandable undesired tissue in excess to
improve decient areas (Robin Hood’s principle of Millard).
Regular preoperative exams are ordered, and in all cases,
preoperative mammography or ultrasound was recommended according to the age to exclude pathology and to
record the breast preoperative morphology. A postoperative
control will be made after 6 months to record the new breast
morphology for future follow-up (Table36.1).
The procedure is performed on an outpatient basis or with
a one-night stay according to the cases. General anesthesia
or local anesthesia plus sedation is generally chosen.
Perioperative antibiotic prophylaxis is administered with 2g
of cephalosporin i.v., and it is repeated if the procedure is
extended more than 3 h.
A meticulous preoperative marking of the areas to be
treated was made.
Table 36.1 Personal technique
• All patients underwent preoperative mammography or ultrasound
according to the age to exclude pathology and to record the breast
preoperative morphology. A postoperative control is made after 6
months
• Anesthesia: general; rarely local + sedation
• Antibiotics: cephalosporin iv
• Preoperative markings of the areas to be treated
• Donor site inltration: wet inltration (1–1). In every 1000cc
ringer lactate, add 1cc adrenalin. If local anesthesia is needed,
lidocaine 2% is added at 0.05%
• Donor site: depending on the patient request for remodelling
• Quantity of harvested fat: about 5cc out of 10cc was useful for
reinjection. Add generally 30/40% due to resorption
• Modality of harvesting: syringes 10cc Luer lock; cannula 3mm
Coleman
• Preparation: centrifugation for 1min
• Position of the patient: supine and then sitting to control
• Injection: several incisions are used in creating multiple
microtunnels; inject multiple sites; multiple directions and planes.
Initially, 10cc syringes are utilized, while for renements 1cc
syringes are used. Small quantities of fat are transferred in each
tunnel to be surrounded by well-vascularized tissue. The fat is
injected slowly in a retrograde way by the withdrawal of the
cannula
• Sites of injection: initially in the retroglandular space to add
volume and then in the subcutaneous plane to reshape the breast
morphology. The fat transfer begins from deep to supercial.
Rigottomies are preliminarily done when needed
• A moderate hypercorrection is obtained previewing fat resorption
in the following 3/4 months. 30/40% more is to be injected
• The injection is stopped before any blanching appearance. It is
important to underline that hypercorrection does not mean in any
case hypergrafting
• Dressing of the breast: just to protect. Dressing of the donor site:
garment as in liposuction
36.3.1 Fat Harvesting
In our experience and according to several clinical evidence
in the literature, no preferred adipose tissue donor site was
evident; depending on patient morphology and desires in
terms of body remodelling, fat can be harvested from different donor sites such as the abdomen, hips, thighs, and buttocks [28–31].
The fat harvesting technique was essentially the same in
all procedures and followed the non-traumatic method recommended by Coleman. Donor site inltration was made
according to the superwet procedure (1:1 principle) adding
1cc of adrenaline to every 1000cc of ringer lactate. In the
case of general anesthesia, local anesthetic was not used
based on its negative effects on ASC founded in some studies
[32]; if the procedure was done in sedation, lidocaine 0.05%
or 0.1% was added.
High-powered machines were not used, and fat was harvested using Coleman connected to a closed low-pressure
aspiration system.
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