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Volumetric andRegenerative
https://t.me/medicina_free
Components ofFat Graft: Positioning
intheFat-Nanofat Spectrum
MarionW.Tapp, KelseyM.Lloyd, AdamJ.Katz,
andRamonLlull
Contents
8.1 Introduction 73
8.2 The Graft 74
8.3 The Spectrum of Fat Fragmentation 75
8.4 Volumetric Potential 77
8.5 Regenerative Potential 78
8.6 A Position on Fat Fragmentation Byproducts 78
References 79
8
8.1 Introduction
Adipose tissue was believed to be a relatively simple organ
with a primary role to protect more “valuable structures” as
it stored fuel. Over the past few decades, advances in the
eld have revealed that adipocytes and their supportive cells
constitute a dynamic organ which we propose to be an organ
of healing [1].
Volumetric interest in adipose tissue began more than a
century ago when the rst adipose tissue transfer was performed by Gustav Neuber in 1893 for periorbital scar correction [2]. Years later, Viktor Czerny would transplant a lipoma
for breast reconstruction and Erich Lexer began fat grafting
of disgured soldiers. These efforts represented en-bloc
transfer of fat tissue, which fell out of favor due to its high
resorption rate and tendency to cause oily cysts. The rst
exogenous injectable used to correct contour deformities utilized parafn wax, which was historically employed to correct syphilitic saddle nose deformities. Parafn, too, was
found to be problematic in that it migrated, created rm nodules, and also caused pulmonary emboli. In 1909, Eugene
M. W. Tapp · K. M. Lloyd · A. J. Katz · R. Llull (*)
Department of Plastic and Reconstructive Surgery, Wake Forest
School of Medicine, Winston-Salem, NC, USA
e-mail: mtapp@wakehealth.edu; kmlloyd@wakehealth.edu;
akatz@wakehealth.edu; rllull@wakehealth.edu
Hollander pioneered the rst injectable fat transfer using ram
fat mixed with minced fat [3]. Nevertheless, due to unreliable volumetric retention over time, injection of fat was
questioned until the advent of liposuction by Fournier and
Illouz in the 1980s and its adoption in the 1990s, when
Sydney Coleman would harness the use of liposuction for fat
injection [2].
The regenerative interest in adipose tissue is relatively
still in its youth. In the 1960s, adipose tissue was enzymatically dissociated into a single cell suspension, which allowed
the ability to study its individual cell components [4, 5]. The
therapeutic, regenerative potential of these cells was rst
conceived by members of our lab and later popularized by
Zuk etal. [6–10]. Prior research showed that connective tissue matrices of other animals contained uncommitted mesenchymal stem cells [11]. Mesenchymal stem cells have the
potential to differentiate into adipocytes, chondrocytes, myoblasts, or osteoblasts [10–13]. Additionally, adipose tissue is
known to derive from embryonic mesoderm and have a heterogeneous stromal cell population much like bone marrow,
where mesenchymal stem cells had been previously harvested [10, 14–18]. Therefore, it was proposed that adipose
tissue may represent a source of stem cells that would be
easy to obtain, and capable of yielding high cell numbers.
Their results supported their hypothesis and paved the way
for future research utilizing these adipocyte-derived stromal
cells (ADSC).
© 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_8
73
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As illustrated in other chapters, the use of adipose tissue
and fat grafting began as an attempt at satisfying the simple
goal of adding volume and has now expanded to nearly endless possibilities. Therefore, much like our understanding of
adipose tissue has evolved, so has the responsibility of plastic surgeons. We must deeply understand the components of
our fat graft as we are ultimately ushering new generations of
cell surgeons: those who, wearing the hat of a cell biologist
and a surgical gown, uncover the volumetric and regenerative properties within the adipose-related biospace. The
foundation to fully harness the potential of fat grafting begins
with our belief that you must “know your graft.”
8.2 The Graft
The quest to rene a lipoaspirated fat tissue parcel into a
graft has driven the entire evolution of fat fragmentation.
While not a novel idea, we conceptualize successful fat
grafting into optimization of ve crucial areas: graft content,
graft procurement, graft processing, the recipient bed, and
the engraftment process. A complete review of all these components is outside the scope of the chapter; however, a few
fundamentals are necessary to establish a knowledge foundation for a post-fragmentation fat graft spectrum and allow
further discussion.
The graft itself begins with understanding the components of the lipoaspirate. The lipoaspirate sample is a complex coarse dispersion in which tissue fragments, composed
of parenchymal (adipocyte) and stromal (mesenchymal) elements, are suspended in a liquid medium [19]. Liposuction
transforms the adipose tissue into a owable medium of
small particles in liquid amenable to injection. This very
transformation from solid tissue to liquid injectable allows
volumetric augmentation with adipose tissue to be a minimally invasive procedure. However, in doing so, the slurry
composition becomes a highly unpredictable graft; oil and
solid components dramatically change from sample to sample, surgeon to surgeon, case after case. We have established
the goal of maintaining viable adipocytes and their stromal
components within a reproducible ratio in respect to their
containing liquid medium, without violating their integrity.
There are numerous ways to do this, but one of the most
popular is centrifugation. Following the Coleman technique
and his described use of the centrifuge, we nd ourselves
with three distinct layers when viewing the syringe [20]. An
oil layer resides on the surface with fatty tissue components
just beneath, and a sero-sanguinous heterogeneous mixture
on the bottom. Systematic removal of oil and sero- sanguinous
layers is paramount to reproducible volumetric retention.
Once removed, we are left with our fatty tissue comprised of
adipocytes and stromal vascular cells. A histological analysis
of the fatty tissue discloses a fragment stratication in which
adipocyte-predominant fragments oat in the supercial
layer, while stromal cell-rich fragments are found in greater
proportion in the lower level [21, 22] (Fig.8.1).
Adipose tissue is composed of mature adipocytes and the
stromal vascular fraction (SVF). The mature adipocyte consists of a large lipid droplet surrounded by cytoplasm and a
plasma membrane. During times of caloric abundance,
energy storage is promoted and adipocytes undergo hypertrophy and hyperplasia [23, 24]. The stromal vascular fraction is composed of stromal reparative cells including
broblasts, pericytes, vascular endothelial cells, and immune
cells. SVF also contains a pool of progenitor cells capable of
proliferation and differentiation [1, 21, 25].
Due to their constitutive reparative properties and representing a substitutive pool to parenchymal adipocytes, the
SVF is a target for further research in tissue regeneration.
SVF may be isolated from the mature adipocytes by collagenase and more recently by mechanical means and then can
be further modied or expanded to isolate those descendant
cells from the precursor fraction in SVF [10, 26–29]. The
constitutive properties and heterogeneous nature of SVF
have been thought to add clinical benet, as opposed to the
stem pool alone, in outcomes such as immunomodulation
and angiogenesis which are critical mechanisms to secure
engraftment when and if the recipient bed is ready [26,
30–33].
The ideal recipient bed should be compatible, adjacent,
perfused, and competent in order to allow successful engraftment. The engraftment process itself returns vascular perfusion to a temporarily parasitic and ischemic fat graft [34].
There are two general theories as to how a fat graft survives:
Graft Replacement vs. Graft Survival. The graft replacement
theory is based on the thought of pre-adipocytes and other
undifferentiated cells being more resistant and less fragile
than adipocytes. Work by Eto and Yoshimura etal. has shown
in their models that adipose progenitor cells undergo activation and differentiation into new adipocytes and thus propose
the nal amount of fat graft retention is based on the graft
replacement by these progenitor cells [35–37]. This is argued
by Peer etal. that believe adipocytes undergo a similar process of engraftment as would a skin graft beginning with
imbibition [38]. This theory was further strengthened by
studies such as Carpaneda and Ribeiro that found adipocytes
within 2mm of vascularized tissue after transplant survive
via imbibition, and by Zhao etal. who demonstrated histologically the survival of graft adipocytes in mice after transplantation [35, 39, 40]. We dare to advance that a more
precise description of engraftment entails an interplay of
these two theories during a four-step process involving the
graft’s implantation, imbibition, revascularization, and
integration.
That being said, as a community we still argue over a
standardized method of fat grafting and boast variable ranges
8 Volumetric andRegenerative Components ofFat Graft: Positioning intheFat-Nanofat Spectrum
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a
Fig. 8.1 Physical composition of a lipoaspirated fat graft (macrofat,
panels A) versus a fragmented nanofat (panels B). Panels A (H&E).
Upon centrifugation (see syringe graphic LEFT), a typical yet highly
variable composition of a standardized fat graft (macrofat) is depicted
from a 10-cc sample: 2cc of oil (yellow, A.1), 5cc of tissue (orange),
and 3 cc of water (blue), containing minimal number of loose cells.
Within the tissue layer, adipose tissue particles stratify immediately
below the oil micelles according to their cell densities and pack themselves in the mid-tissue layer: those rich in buoyant adipocytes on top
b
(panel A.2), those rich in stroma on the bottom (panel A.3). Panels B
(Oil red O). In contrast (compare above to syringe graphic RIGHT),
nanofat fragmentation renders a signicantly higher volume (5cc) of
emulsied oil on top in which 500μ tissue fragments (panel B.1), a
densely populated tissue fraction with progressively decreasing number
of adipocytes (2cc, B.2). The tissue fragments immediately over the
water phase are constituted by heavy ber and vascular structures (B.3).
Of note, centrifugation deposits a pellet of scant bers and isolated cells
(50,000 cells/ml of tissue) with low viability (not shown)
of graft take [41]. It is our rm conviction that the knowledge
of the graft’s physical (water and oil contents) and biological
(graft) composition is key to optimize outcomes for all
patients. Once the graft composition is truly reproducible,
then a greater scientic appreciation of adipose tissue
engraftment and its components will usher in a new world
where fat grafting lends itself to not only volumetric but also
regenerative capabilities.
8.3 The Spectrum ofFat Fragmentation
Fat grafting has evolved to meet specic demands of both the
surgeon and the scientist, demanding reproducibility and
understanding, while minimizing donor volume requirements and implantation morbidity. This has been done
through mechanical fragmentation of the graft, thus reducing
its particle size while optimizing its implantation. Quite
unexpectedly, the apparent cell injury caused by mechanical
fragmentation did not result in an increment of morbidity,
but rather to a trend of reports conrming both volumetric
enhancement in addition to trophic changes in the overlying
skin and adnexa.
Our sequence of studies on the fat fragmentation byproducts and their histological structure, cell quantity and viability, allows us to present the conceptualization of fat grafting
on a spectrum in which particle size correlates directly with
the volumetric potential of mature adipocytes and inversely
with the regenerative potential of stromal cells.
We will focus specically on the spectrum of fat particles
achieved from liposuction as produced through harvesting,
with liposuction cannula size thought to correlate with particle size [42]. This spectrum is loosely divided into the
unscientic, inconsistent terminology such as macrofat,
microfat (or millifat), and nanofat (Table8.1).
By popular convention, macrofat is the fat particle size
correlated with use of large bore cannulas, typically 2–3mm
in size, with larger side ports [43]. In the landmark paper by
Tonnard etal., he used a 3-mm Mercedes-type liposuction
cannula with side ports measuring 2×7mm. High-negativepressure liposuction was used and the lipoaspirate was rinsed
and ltered using a nylon cloth [44]. Upon analysis of the
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M. W. Tapp et al.
Table 8.1 The spectrum of fat fragmentation
Macrofat Microfat Nanofat
Process Collection Collection Post
collection
Size 2–3mm 1mm <1mm
Composition Adipocytes and
SVF
Application Volumetric Volumetric Regenerative
Reduced
adipocytes
SVF
SVF
macrofat, Tonnard et al. found viable adipocytes with few
dead cells and overall normal histological structure [44].
Macrofat was placed in small aliquots to maximize diffusion; however, the limiting factor upon injection is the cannula as it must allow for the larger fat particles to pass
without further fragmentation or clumping. Larger fat particles and more viable adipocytes make macrofat the preferred
source when considering volumetric correction, in particular
when implanted in deep planes.
We dene microfat as the fat particle size correlated with
use of liposuction cannulas with smaller side ports, typically
1mm in diameter [43, 44]. Tonnard and his team harvested
and processed the microfat in the same manner as that of the
macrofat. Despite the smaller side ports on the cannula, qualitative histological analysis of the adipocytes was found to be
similar both in structure and viability to that of the macrofat
[44]. Since microfat grafting is often utilized in the facial
region and uses smaller blunt-tipped cannulas often ranging
as small as 0.7mm, microfat is preferred to macrofat as it
allows smooth injection which would likely result in less
irregular fat deposition [44]. Microfat grafting offers the
volumetric benets of macrofat grafting in areas that have
more shallow implantation sites and lower volumetric
requirement.
Both macrofat and microfat are adipose tissue fragments
generated by suction-assisted mechanical force. This is in
contrast to nanofat which is a fat particle generated when the
above macro- or microfat grafts are further fragmented post
collection [43, 44]. The fragmentation is classically described
by transferring fat grafts between two syringes connected by
a Luer-lock connector 30 times resulting in a milky (Tyndall
effect) emulsication of the fat. The liquid is then ltered
over a nylon cloth, leaving an efuent rst termed nanofat by
the Belgian group [44].
Nanofat grafting is typically combined with microfat
grafting and is injected using a 27-gauge needle. Analysis of
nanofat reveals complete disruption of adipose tissue structure with no viable adipocytes; however, the SVF and CD34+
cell count resembled that of the microfat [44]. SVF and the
CD34+ subset are obtained via enzymatic dissociation of
only collagenase-sensitive cells, which remain unchanged in
micro versus nanofat samples. The issue is in the enzymatic
digestion itself which results in an unrepresentatively small
fraction of cell species that actually colonize the adipose tissue [45].
In fact, and due to the lack of adipocytes which ultimately
results in low volumetric potential, nanofat is considered a
misnomer by many, as critics voice the fact that there is nothing nano in nanofat [43]. Still, the benet of nanofat grafting
remains in its regenerative potential and case reports accumulate supporting a rejuvenation effect [44].
The adipose tissue fragmentation process has not been
fully elucidated previously, but a recent study by Kang etal.
claried some of the cellular processes involved. In their
study, they revealed the underlying cellular injury mechanism associated with mechanical impact is more dependent
on pressure than acceleration. Their study shows that cellbursting pressure generates localized compressive/tensile
pressure cycles that induce intracellular cavitation bubbles,
more so than acceleration-induced pressure, resulting in cell
death [46]. This injury mechanism can be applied to the fat
fragmentation spectrum and explains why mature adipocytes, larger in size and loaded with a highly viscous triglyceride droplet, are the most fragile cell population when
exposed to compressive-tensile pressure cycles. Since mature
adipocytes account for nearly the total amount of volume in
an aspirated fat particle, preferential lysis of adipocytes during processing compromises the clinical potential of processed tissue fragments when grafted to restore volumetric
defects. Yet, by the same reason, adipocyte lysis signicantly
concentrates the stromal cell component, vastly retained in
the tissue layer, responsible for regenerative applications
[47]. In other words, higher degrees of fragmentation result
in an increasing number of viable stromal cells relative to
adipocytes in the sample.
As mentioned before, adipocyte stroma consists of cell
lineages including brocytes, angiocytes, and histiocytes.
They represent the stromal support to the adipocyte parenchyma and remain attached to vascular axles after adipocyte
stripping. These critical cells account for the upkeep of the
tissue matrix in addition to comprising the vascular network
and immunomodulatory properties: the precise mechanisms
sought after in site-specic regenerative therapies. This is the
reason highly fragmented fat grafts, such as nanofat grafts,
garner so much attention.
In short, the fat grafting spectrum ranges from macrofat to nanofat based on the amount of disaggregation. As
fat particle size is reduced so is the volumetric potential,
yet the regenerative potential remains due to the presence
of the smaller SVF cellular components. Perhaps inspired
by French Surgeon, Le Fort, who published his iconic
study reviewing facial bone fracture patterns following
repeated trauma using cannonballs and bats; we believe
that further studies of fat disaggregation will reveal that as
fat particle size is reduced, that it fragments in predictable
way [48].
cd
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8.4 Volumetric Potential
Volumetric potential is the ability of a fat graft to provide
volume. In a fat graft sample, the greatest volumetric factor
is that of the viable adipocyte and therefore volumetric
potential is greatest in a macrofat graft with lesser potential
in microfat graft. Volume has historically been a subjective
measurement of the perceived alteration in the contour of the
overlying skin although objective measurements may now be
obtained through the use of imaging including magnetic resonance imaging (MRI) and 3-dimensional (3D) surface
imaging [49–51].
The volumetric potential in fat grafting often seems more
of an art than a science as retention rates may range from 25
to 70% [41]. Additionally reviews of grafting for volume restoration present variable results [52, 53]. Beyond the lack of
standardization in physical and biological graft composition,
a compelling factor underlying dubious reproducibility and
reliability is the lack of outcome metrics.
For long-term success, we expect that volume retention is
directly related to fat viability. Therefore, we must strive to
achieve reproducibility via optimizing the physical and
physiological conditions of the fat graft, which are based on
our optimization of the ve essential steps of fat grafting outlined earlier.
An issue with the above statements is the assumption that
injecting 1cc of fat graft would equal a direct volume change
of 1cc in the recipient bed. Dos Anjos etal. directly evaluated this using two measurements: Intraoperative Volume
Restoration Index (IVRI) and Postoperative Volume
Retention Index (POVRI) [54] (Fig.8.2). IVRI is conceptualized as the comparison of measured volume change versus
volume injected. Using 3D scanning models, these authors
objectively measured their intraoperative changes in volume
following fat grafting to the breast. They found that the measured changes in volume were never equal to that of the graft
placed. In fact, the majority of scenarios resulted in an
Intraoperative Volume Restoration Index of 85–92% of the
injected volume. Upon further exploration, they attempted to
measure the IVRI with placement of silicone implants.
Silicone implants are a more cohesive structure and therefore
one might expect an IVRI of 1; nevertheless, the authors
found values of only 0.84 (84%). The authors proposed that
this phenomenon is likely due to either the viscoelastic
behavior of both the breast and graft or possibly due to packing density [54]. In addition to the challenge posed by a graft
that is subject to wide ranges in viability, we now are faced
with the predicament that if even 100% of our graft were
viable, it would not correlate to a 1:1 volume restoration in
the body. The authors propose this is more reason to strive
for reproducible fat grafting results so that the surgeon may
accurately predict surgical outcomes, once again lending to
the thought of fat grafting being a combination of art and
science.
ab
Fig. 8.2 The concept of volumetric restoration and retention
The Intraoperative Volume Restoration Index (IVRI) provides the practitioner with a quantication of how much graft is needed to satisfy
(restore) a volumetric decit. It is counterintuitive to realize that the
graft volume (A) plus the initial breast volume (B) does not equal the
immediately post-grafted breast (C), but it is actually consistently inferior to that addition. The Postoperative Volume Retention Index
(POVRI) is the ratio between the breast volume at a given postoperative
time (D) over the volume achieved immediately post graft (C). POVRI
allows the practitioner to quantify the fraction of volumetric resorption
resulting from non- viable (gray) fat grafts and determine when the
reabsorption subsides. Both parameters will aid the practitioner to consequently predict the graft volume (A) requirements to reach the necessary overcorrection at a given postoperative time
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In the age of extensive research in SVF and ADSC, clinicians have explored the volumetric potential of augmenting
fat graft with these constituents. The same authors that proposed IVRI and POVRI explored this potential [54]. They
studied the “dose” effect of adding SVF to adipose graft to
observe long-term volume retention rates. In doing so, they
injected 77 fat grafts with 21 enriched with low dose of SVF
cells and 56 enriched with high SVF cell doses. The low
doses were dened as <50,000 SVF cells, considered to be
inconsequential and thus the control group. The high dose
was dened as SVF cells >200,000. They measured outcomes with POVRI dened as the change in postoperative
volume compared to pre-operative values using the 3D imaging software. In their study, they found that initial volumes
decreased, but over time the high-dose SVF samples had signicantly higher volumes compared to the low-dose group
with long-term retention at 1.5 years of 75% of the initial
injected volume [54]. The results of their study are not isolated; in fact, other studies have utilized SVF and ADSCs
and shown increased retention rates as well [55, 56]. These
results are conicting compared to other studies which did
not reproduce these same results [49, 57]. Chiu et al. argue
against use of SVF as they did not nd signicant retention
rate differences in their fat grafting. They felt patients are
better served by avoiding the excess liposuction required for
the SVF and saving those donor areas to be utilized at a later
time for additional grafting if needed [49].
The principle of volumetric potential with the added SVF
is based on the hypothesis that the constitutive cells of the
stroma provide cellular supportive functions including cellular repair via broblasts, improved vascularity via endothelial and perivascular elements, and immunomodulatory
control via immune cells [54, 58–61].
While the foundation of volumetric potential is based on
proper harvesting, processing, and engraftment, there
appears to be a role for optimization of grafts with SVF and
adipose progenitor cells and will be the focus of continued
research in the future.
In relation with the above, a new parameter has been
described with intriguing applications in facial rejuvenation:
the surface-volume coefcient [62]. Cotofana and coworkers
demonstrate that the different injection volumes necessary to
deliver aesthetically appealing results when utilizing the subdermal vs. the supraperiosteal technique can be predicted by
the region-specic surface volume ratio.
and clinical outcomes remain highly elusive especially in
regard to their beseeched regenerative properties. In lack of
precise characterization of highly fragmented graft and
quantication of clinical effects, a raising body of experimental evidence allows one to speculate on nanofat’s mechanisms of action.
The regenerative potential of fat grafting is based on the
interaction of the SVF and its resident progenitor. The effect
can be thought of by two key mechanisms that are likely synergistic in nature: the substitutive effect and the supportive
effect. The substitutive effect is based on the thought that
parenchymal cells (adipocytes) may be replaced or substituted by precursors found in the stroma. This includes both
pre-adipocytes (adipocyte-committed precursors) that have
already been differentiated and more primitive progenitor
cells that still retain the potential to differentiate into other
non-adipocytic cell lineages [1, 10–13, 21, 25]. The support-
ive effect mentioned previously is based on the blastic potential that broblasts, endothelial cells, immune competent
cells, and others express in the SVF.
Nanofat is composed predominantly of stromal elements
and non-viable adipocytes dispersed in the emulsication
process. This renders a graft with no volumetric potential,
but apparently with high regenerative potential: Lipolling
has been known to produce skin regeneration in the setting of
radiation and scarring [44, 63–65]. The mechanism is thought
to be secondary to the potential of the SVF ultimately resulting in increased production and remodeling of collagen and
elastin [44]. Since Tonnard’s original paper, research has
shown nanofat possesses the ability to improve hypertrophic
scars, atrophic scarring, skin pliability, rhytid attenuation,
and rejuvenate skin [28, 66–70]. The effects of nanofat grafting is typically delayed with results in 4weeks up to 3months
[44].
The regenerative potential of fat grating continues to be
studied and as of 2016 there were over 130 active clinical
trials investigating the potential of ADSCs [71]. Some of the
most highly reported applications include bone regeneration,
fat reconstruction, cardiovascular and myocardial regeneration, cartilage and intervertebral disc regeneration, hepatic
regeneration, pancreatic preservation, and vascular augmentation in transplanted tissue [29, 72–83]. Further regenerative
capabilities of adipose tissue continue to evolve due to the
overall abundance and ease of accessibility to this tissue.
8.5 Regenerative Potential
Graft standardization and outcome metrics are currently
advancing to improve reproducible and reliable surgical performance for large, minimally fragmented grafts. When it
comes to smaller, highly fragmented grafts, standardization
8.6 A Position onFat Fragmentation
Byproducts
Successful use of fat grafting, whether for volumetric or
regenerative indications, relies on the principle of “knowing
your graft.” Adherence to standardizing and optimizing each
step of the fat grafting process will ensure reproducible
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results and better outcomes for our patients. Modulating the
fraction of volumetric over regenerative components of adipose tissue via mechanical fragmentation may well satisfy
both volumetric and regenerative clinical requirements.
Conceptualizing the grafting options over a spectrum of
these different fragmentation byproducts (macrofat to “nanofat”) is already contributing to stimulate discussions and
innovation on fundamental aspects of structural and functional aspects of tissue repair.
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Fat Transfer toImprove Results after
https://t.me/medicina_free
Breast Surgery andinBreast
Abnormalities
M.W.Payne andJ.M.M.Nijboer
Contents
9.1 Asymmetries 83
9.2 Correction of Breast Augmentation Complications/Imperfections 85
9.3 As Part of Correction of Breast Abnormalities 86
References 87
9
Breast abnormalities, i.e., tubular breast deformity, Poland’s
syndrome, signicant asymmetries (between breasts or
thorax halves), after trauma or surgery, are difcult to deal
with for both patient and surgeon. Expectations are high,
surgical procedures are plenty, and disappointments are
frequent. Equally challenging are certain unfavorable
results after breast surgery, no matter how experienced the
surgeon.
Often the results after corrective procedures are acceptable but not completely satisfactory, for all parties involved.
An improvement is achievable for an experienced surgeon.
However, often a degree of “imperfection” remains postoperatively. If the patient is unsatised with the nal result,
often the only solution seems to reoperate but unfortunately
without guarantee of success. The key is, and always will
be, to create realistic expectations before any procedure,
especially in these complex cases. Fat transfer does not
change that.
Fat transfer gives us, besides volume increase, the possibility to even out irregularities in a subtle way, not achievable
with other surgical procedures. The particulars and pitfalls of
Supplementary Information The online version contains supplementary material available at https://doi.org/10.1007/978- 3- 031- 10881- 5_9.
M. W. Payne (*)
Private practice for plastic and cosmetic surgery,
General Guisan - Quai 30, Zürich, Switzerland
J. M. M. Nijboer
M1 Med Beauty Swiss, Zürich, Switzerland
fat transfer are discussed in previous chapters. This chapter
will illustrate its usability to improve aesthetics in patients
with breast abnormalities and/or unfavorable results after
breast surgery.
9.1 Asymmetries
Naturally asymmetric breasts are the rule rather than the
exception. In case of a volume discrepancy, the correction
involves making a larger breast smaller, a smaller breast
larger or a combination of the two. Often correcting the volume is not enough and a shape modication, with changing
the nipple position and/or breast shape, is necessary. Without
fat transfer, adequate volume augmentation may result in a
volume balance but with an unnatural appearance of the
smaller breast, with the larger implant aspect being relatively
evident. A solution is to increase the soft tissue cover with fat
transfer.
Beware of abnormalities due to boney causes, i.e. scoliosis, asymmetries between ribs, pectus carinatum and excavatum. Although the latter are more common in males,
regularly we see light forms in women, resulting in postoperative asymmetry. Often the patient is unaware of the
abnormality before the operation, but will notice the asymmetry afterwards. A combination of the right implants and
fat transfer may limit its manifestation but addressing it preoperatively (documenting in informed consent) remains of
vital importance.
© 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_9
83
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