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316
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J. Aso and I. González
Key Points
MRI is considered the gold standard when assessing the integrity of an implant.
17.7.1.6 Breast Implant-Associated
Anaplastic Large-Cell
Lymphoma (BIA-ALCL)
BIA-ALCL is an uncommon lymphoproliferative
disorder that has been diagnosed in association
with breast implants. The rst reported cases of
anaplastic T-cell lymphoma date from 1997. In
2006, the World Health Organization recognized
breast implant-associated ALCL (BIA-ALCL) as
a distinct entity from other forms of ALCL.
Multifactorial etiology and lack of exhaustive
registers of both implanted devices and diagnosed cases are a considerable obstacle to determine incidence and risk factors of the disease
(the highest incidence currently reported is of
1/2.832 in the Australian population). All cases
of BIA-ALCL have been correlated with textured
implants. Interestingly, the risk is increased for
implants with higher surface area and surface
roughness. These ndings corroborate the
hypothesis that biolm may promote a chronic
subclinical inammation, which in predisposed
patients may produce the T-cell degeneration.
Textured breast implants in fact harbor signicantly more bacteria compared to smooth
implants due to increased surface area and are
associated with a greater lymphocytic inltrate.
Mutations in gene p53 have also been identied as a risk factor. The disease usually arises
8–10 years after implant placement as a cold
seroma. In early stages, inltration of malignant
cells is limited to the periprosthetic uid and capsule. Its immunohistochemical markers are uniform expression of CD30 protein and
ALK-negative phenotype.
National Ministry of Health protocols have
been developed for diagnoses and multidisciplinary treatment of the BIA- ALCL. Implant
removal and capsulectomy are part of the treatment and in most of the cases sufcient for the
complete resolution of the disease.
17.7.1.7 Mondor Disease
Mondor disease is a mild, self-limited complication consisting of a palpable “string” usually
crossing the IMF in an upward/downward fashion. It is caused by the supercial thrombophlebitis of the inferior veins of the breast. It may occur
in up to 2–3% of augmentation patients. Its incidence appears to be higher when using inframammary incision. As previously noted, it is
self-limited and resolves during the course of
several weeks.
17.7.1.8 Galactorrhea
Galactorrhea is dened as a secretion of breast
milk not associated with nursing or childbirth
[42]. As a general rule, patients should not
undergo aesthetic breast surgery prior to a
12-month period after giving birth or halting
postpartum lactation. If milk production is still
present, it can be medically interrupted with presurgical regimen of dopaminergic agonist (usually bromocriptine).
Although unusual (<1%), galactorrhea may
present after breast augmentation; this is more
frequent in patients who previously breastfed
[43, 44]. Milk production is not considered harmful in itself, but may lead to galactocele (milk
accumulation around the implant) and secondary
infections. Inframammary approach and submuscular positioning of the implant are protective
conditions against galactorrhea, galactocele, and
infections [45–47].
In most cases, milk secretion is transient and
not associated with higher prolactin levels.
However, serum prolactin levels may be elevated
as a consequence of direct mechanical stimulus,
prolactin-secreting prolactinoma of the pituitary
gland, or more complex hormonal dysfunctions
such as hypothyroidism and adrenal insufciency. Pharmacological anamnesis should specically investigate neuroleptic or psychiatric
drug assumption that may inuence prolactin levels through dopamine release inhibition.
Prolactin serum level should be determined,
along with thyroid hormones: thyrotropin-
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317
stimulating hormones T3 and T4. If the levels are
abnormal, an MRI should be considered in order
to rule out pituitary adenoma. If serum prolactin
levels are high, the patient should be referred to
an endocrinologist/gynecologist. In the case of
normal prolactin levels, medical treatment may
not be necessary [3].
Ultrasound examination is helpful to determine whether liquid accumulation is present
around the implant at an early stage; drainage is
performed whenever possible to conrm milk
presence and to rule out active infection.
Although galactorrhea is somewhat common
after breast augmentation, complications derived
from it are very rare in our practice (<1/1000).
17.7.2 Aesthetic Drawbacks
17.7.2.1 Implant Malposition
Malposition is a common problem associated
with breast augmentation and one of the most
common reasons for revisional surgery. This
occurs in about 1.2–1.6% of cases.
Malposition may present with different aesthetic deformities, which may respond to two different situations:
– The rst dened as a “malrotation” is basi-
cally an implant malposition consisting of an
inward or outward rotation of the axis in the
frontal plane resulting in an unpleasant aspect
of the breast. Minimal rotations (<15°) are
rarely noticed from the patient and thus do not
require reoperation. Round implants are obvi-
ously not susceptible to rotation, only anatom-
ical ones. The ip over of the implant is rare
and may also be considered as 180° rotation
on the vertical axis; it is usually associated
with a punctual mechanical stress of the
breast, and round implants may also ip over.
– The second dened as implant displace-
ment is an erroneous location of the implant
in relation to the desired footprint. The
implant can be dislocated medially, laterally,
superiorly, or inferiorly resulting in aesthetic
unpleasant results. Bilateral medial displace-
ment of the implants may cause symmastia,
which is a dreadful complication for its
renown difcult resolution. We consider
“double-bubble” deformity (double prole of
the inferior pole) as a consequence of an
excessive lowering of the new IMF in patients
with high/well-dened preexisting IMF and
developed breast.
The superior displacement of the implant
rarely causes a double-bubble deformity but
more likely an overlled upper pole and NAC
“looking down.” The “waterfall” deformity is a
very frequent nding and consists of a sliding
ptosis of parenchymal breast tissue over a xed
(usually submuscular) or encapsulated implant. It
is rather a long-term consequence of breast ptosis
or, if seen early, a poor indication (missed augmentation mastopexy, retromuscular implant
position). It is important to keep in mind that if
the implant is placed in a submuscular pocket and
no dual-plane technique is used, both units
(implant and breast parenchyma) will behave
independently, not as one. Thus, the prosthesis
lies correctly on the chest wall, but the gland
“falls” over it; the treatment implies secondary
mastopexy for most of the patients.
Malposition is normally the consequence of
loose tissue and nonadherence of the implant. It
usually occurs over time and is more frequent in
smooth implants. It is also possible in the case of
inadequate pocket size.
Attention
It is important to keep in mind that if the implant
is placed in a submuscular pocket and no dualplane technique is used, both units (implant and
breast parenchyma) will behave independently,
not as one.
17.7.2.2 Wrinkling andRippling
Wrinkling/rippling is a frequent occurrence
observed with the saline implants (over 35%) and
retroglandular implant positioning especially
when implant-to-parenchymal ratio is greater
than 50%. It is due to the visibility of the corrugations of the implant surface.
It is not uncommon to notice rippling after
pregnancy and/or years after breast augmentation
318
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J. Aso and I. González
since hormones and aging may induce soft-tissue
thinning.
Evaluation of implant positioning related to
soft-tissue thickness is the most effective tool to
avoid this kind of complications. Secondary lipolling and change to a submuscular and partialsubmuscular plane are both effective solutions.
17.7.2.3 Asymmetries
Some asymmetry is present in all breasts; it
should be pointed out and discussed before surgery. Signicant asymmetries of volume may be
corrected with different implant sizes and different shapes, and nipple position may be hard to
correct or require additional procedures such as
lipolling or periareolar incisions.
It is important to determine the limit of each
procedure and be sure that they meet the patient
expectations.
17.7.2.4 Sensory Changes
Sensory alteration may occur after breast augmentation; they are usually transient and are not
usually reported as a signicant problem for the
patient. Periareolar approach is the more relevant
factor associated with NAC sensibility problems.
Sensory alterations have also been related with
big implant volumes >350cc for both soft-tissue
stretching and wider dissection. Anatomical studies describe that relevant NAC innervation comes
from intercostal branches, especially of the fourth
intercostal nerve. Preservative dissection in the
lateral aspect of the pocket is preferred in order to
let the implant bluntly and progressively dissect
the most lateral aspect of pectoralis major-minor
interface where the intercostal nerves perforate
the fascia. Even with these precautions, the incidence of nipple sensitivity permanent alterations
is about 4%.
17.8 Conclusions
Post-maternity patients usually complain of lack
of volume and fullness of the upper pole, along
with loose skin, due to the anatomical changes
after pregnancy. Breast augmentation is a safe,
high-satisfaction procedure in these patients, pro-
vided that the nipple-areola complex is not positioned below the inframammary fold
(augmentation mastopexy should be considered
in these cases).
With a single operation, we are able to:
– Restore the volume lost after pregnancy/
breastfeeding or even get a larger cup than
before
– Tighten the loose skin of the breast
– Give a more “lifted” look of the breast with
the right technique (dual plane, anatomical
implants), due to the upward movement of the
nipple-areola complex without the need of a
mastopexy
Patients should be very well informed about
the possible outcomes and drawbacks. Meeting
the expectations is the single most important
thing when trying to achieve a successful procedure and a happy patient.
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Fat Grafting Augmentation After
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Breastfeeding
JoseMariaSerra-Mestre, EdisonFranco-Gonzalez,
andJoséMariaSerra-Renom
18
Take-Home Points
• To correct the changes produced after pregnancy or breastfeeding, augmentation techniques are commonly used in combination
with periareolar, vertical, or Wise pattern
mastopexy.
• Composite breast augmentation can address
the inherent limitations of prosthetic implants.
It corrects localized asymmetries, reduces the
distance between the breasts, and optimizes
the results simply and safely using smaller and
lighter implants.
• Fat grafting alone is a useful technique in
medium-sized or large breasts. However, the
increase in volume that can be achieved in a
single session is limited.
18.1 Introduction
The hormonal changes during pregnancy, postpartum, and post-lactation period produce a
series of variations in the breast [1–3]. To prepare
for lactation, the breasts increase in volume,
change shape, and alter their sensitivity. As for
the nipple, both its color and its size are affected
by the growth of the glandular parenchyma and
its secretory units.
Once the breastfeeding period is over, major
histological changes begin such as apoptosis of
the epithelial cells and secretory units, which are
replaced by adipose tissue and lose the dimensions gained previously in a process known as
breast involution [4]. This often results in signicant losses of breast volume, ptosis of the nippleareola complex, and loss of skin turgor and
elasticity.
The correction of these changes is a challenge
for the plastic surgeon. Several options are available to recover the structure and aesthetics of the
breasts, using breast augmentation or mastopexy
techniques with implants or fat grafting [5–7].
Fat grafting has now become a widely used
technique not only as a complement to other
breast surgeries for improving breast contour and
symmetry, but also as an alternative to implants
in cases of augmentation, mastopexy, or breast
reconstruction [8, 9].
In this chapter, we describe the indications
and the use of fat grafting in augmentation and
mastopexy patients after postpartum and breastfeeding changes.
J. M. Serra-Mestre (*) · E. Franco-Gonzalez ·
J. M. Serra-Renom
Plastic Surgery Department, Hospital Quirón
Barcelona, Universidad Internacional de Cataluña,
Barcelona, Spain
© Springer Nature Switzerland AG 2023
M. Gomes-Ferreira, J. Olivas-Menayo (eds.), Post-maternity Body Changes,
https://doi.org/10.1007/978-3-030-43840-1_18
321
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J. M. Serra-Mestre et al.
18.2 Patient Selection
When the hypotrophy is not accompanied by ptosis or if the patient presents a pseudoptosis, the
correction can be achieved by performing a breast
augmentation with implants [5], fat grafting, or a
composite technique [6]. In cases of more severe
sagging, the augmentation must be combined
with mastopexy techniques [7].
18.3 Preoperative Evaluation
18.3.1 Physical Examination
Our technique of choice for breast augmentation
involves a composite approach with fat grafting
and the insertion of a silicone implant at subfascial or submuscular level via an endoscopyguided axillary approach.
In these cases, when the patient has a pinching
test result less than 2 cm, the submuscular
approach is used. In patients with a pinching test
result more than 2cm, in whom large increases
are unnecessary, and in professional athletes who
wish to retain the pectoralis major muscle in its
entirety, subfascial dissection is preferred.
If the aim is to raise the nipple-areola complex
up to 3cm, a periareolar technique is used [10]. If
the distance from the sternal notch to the nipple is
less than 28 cm, we use our vertical scar technique [11]; but if the distance is above 28cm, we
prefer a “T” scar technique using the Wise pattern in order to obtain a more rounded shape [12].
18.3.2 Markings
Fat grafting is always performed once the surgery is nished, so injection points and areas to
be fat grafted are chosen and marked after surgery with the patient seated. In our opinion, this
allows the surgeon to have a more precise control
in correcting asymmetries and giving volume to
the breast.
18.4 Anesthetic Considerations
When surgery is performed under general anesthesia or sedation, we create the tumescence of
the donor area using a saline and adrenaline solution at a ratio of 500cc saline solution, 1mg of
adrenaline, and 20cc of lidocaine 2%.
When surgery is performed under local anesthesia in a second operation to optimize the outcome, 2 h prior to surgery, the donor area is
covered with a topical anesthetic cream (EMLA
TM). At the time of surgery, we inltrate a small
quantity of undiluted anesthetic at the two entry
points. We then create the tumescence with a
30 cc solution of 2% lidocaine and 0.5 mg
adrenaline.
18.5 Surgical Technique
18.5.1 Patient Positioning
Correct surgical positioning is important. In all
cases, the patient’s arms are extended and held in
place at an angle of 90° at the height of the armpit. The gluteal region coincides with the fold of
the table, to allow the patient to remain seated
during surgery.
Prior to surgery, we mark the reference lines with
the patient in standing position. The midline is
marked from the sternal notch to the navel, and
the width of the breast is obtained marking the
anterior axillary line and a line 1.5cm from the
midline. Also the current inframammary fold and
the orientative point where we will place the new
one are marked at the level of the sixth rib plus
half the thickness of the pinching test.
18.5.2 Procedures Step-by-Step
18.5.2.1 Breast Augmentation
In small breasts in which the sagging is limited,
or in medium-sized breasts in which the upper
pole is seen to have lost volume but the sagging is
limited, in our opinion, the best solution is to
increase breast volume with implants or a combi-
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Table 18.1
mentation techniques
Technique Advantages Disadvantages
Implants
Fat
grafting
Composite
techniques
Advantages and disadvantages of breast aug-
– Reliable and
predictable
results and
breast size
– Can be easily
removed
– No implant
used
– Small incisions
– Breast look and
feel natural
– Quick recovery
– Improves body
contours
– Smaller
implants
– Customized
shape
adjustments
can be
performed
– Improve body
contours
– Implant-related
complications:
capsular
contracture,
rupture, implant
exchange
– Recovery period
– Scars
– Donor-site
availability
– Limited- volume
augmentation in
a single stage
– Fat resorption
– Prolonged
operating time
– Implant-related
complications
nation of implants and fat grafting. This composite technique allows the use of a smaller implant,
which helps to improve the results, but fat grafting alone achieves only a limited volume increase
in a single session and may not meet patients’
expectations (Table18.1).
Although this procedure can be performed
through the areola or the inframammary fold, our
technique of choice is transaxillary endoscopic
breast augmentation [5], in which a 3 cm long
incision is made in the uppermost horizontal fold
of the axilla. After locating the edge of the pectoral muscle, the plane between the pectoralis
major and minor muscles is opened using
Metzenbaum scissors.
A blunt dissection is then made towards the
fourth rib until the attachment of the pectoralis
major muscle can be felt. The muscle is detached
at the fourth, fth, and sixth ribs with the SerraRenom endoscopic retractor (Snowden Pencer,
Tucker, GA, USA) and a 10 mm 0° telescope,
and a coagulation and suction endoscalpel. The
muscle bers at the sixth rib are sectioned from
the axillary line to within 1.5cm of the edge of
the sternum.
In almost all patients undergoing breast augmentations, the inframammary fold must be
moved downward. This is done under endoscopic
view using blunt dissection. Hemostasis is then
performed if necessary. The denitive implant is
then inserted.
In cases of composite breast augmentation [6],
the fat is injected homogeneously in the soft tissue envelope overlying the implant, especially in
the upper pole and the medial quadrants. In these
cases, we use varying amounts of fat, between 60
and 150cc, depending on the patient.
If the increase is mainly carried out with
implants, fat grafting is also a useful complement
to remodel the cleavage or to correct asymmetries detected in one or both breasts [13, 14].
18.5.2.2 Augmentation Mastopexy
Techniques
In cases with more severe breast hypertrophy or
ptosis, lifting techniques combined with reduction or augmentation are necessary [7]. In these
cases, and depending on the amount of breast
present after lifting, the increase is made with fat
alone or with the insertion of a small implant in
order to improve the projection of the breast and
achieve correct lling of the superior quadrants.
If the aim is to raise the nipple-areola complex
up to 3cm, a periareolar technique is used [10].
The Hammond technique can also raise the complex beyond this height, though some retouching
of the scar will probably be required in a later
surgical procedure. This technique may not be
feasible if the skin is accid or in poor condition,
especially in the lower pole (Fig.18.1a, b).
In cases of more severe ptosis, if the distance
from the sternal notch to the nipple is less than
28cm, we use our vertical scar technique [11]; if
the distance is above 28cm, we prefer a “T” scar
technique using the Wise pattern in order to
obtain a more rounded shape [12] (Fig.18.2a–e).
During the fat grafting, in order to be able to
assess the results as we inject the fat, we place the
patient in the seated position on the operating
table. Multiple injection points are made in a
clockwise direction in order to increase the whole
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J. M. Serra-Mestre et al.
Fig. 18.1 This 49-year-old woman had asymmetrical
breasts and ptosis. She is seen before a periareolar
augmentation mastopexy (a) and 12months after surgery
(b). In this case, we performed a composite technique
breast homogeneously, introducing the fat with a
blunt cannula in several different areas creating a
mesh or crisscross pattern and making tunnels at
all levels to prevent the accumulation of fat.
After this rst phase of volume increase, we
with 220 cc moderate round-shape and smooth silicone
implants (POLYTECH, Health & Aesthetics, Dieburg,
Germany) and 170cc of fat in each breast
After the tumescence, the fat is obtained
through low-pressure liposuction (0.5atm) using
2.4mm microport harvester cannulas with barbed
and beveled 1mm ports (Tulip Medical Products,
San Diego, California, USA) [16, 17].
perform a selective injection of the areas to be
remodeled, such as the cleavage, or in order to
correct asymmetries that may appear after the
mastopexy is performed.
We nish with a 6-0 suture in each of these
holes and immobilize the area with hypoallergenic adhesive plasters to prevent the movement
of the grafts.
Fat Processing
Once obtained, the fat needs to be isolated from
the blood, debris, components of the tumescent
solution, and oil resulting from the breakdown of
fatty acids during aspiration. This is done using
centrifugation, decantation, or washing [16].
There is no consensus regarding the best tech-
nique, as there is still a high degree of discor-
18.5.2.3 Fat Grafting
dance due to the inconsistent results obtained
from animal and human studies.
The donor site most frequently used in breast surgery is the periumbilical area. However, in thin
patients with abdominal sagging, the inner thigh
or knee is usually chosen. In the literature, there
is no consensus regarding the best donor site.
Some authors favor the lower abdomen, where it
is believed that there is a higher concentration of
stem cells, but others see no particular advantages between the possible donor sites [15].
Fat Harvesting
Although there is no general agreement, in our
clinical practice, we use centrifugation, ltration,
and decanting for structural fat grafting and have
obtained similar results.
In the case of centrifugation, we use an oblique
centrifuge for 2 min at 2000 rpm. Once centrifuged, three levels can be observed. The lower
level contains blood and components of the
tumescence solution; the middle layer consists of
small lipomas; and the top layer contains oil
cd
18 Fat Grafting Augmentation After Breastfeeding
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a
b
e
Fig. 18.2 A 42-year-old patient came to our clinic with a
grade IV capsular contracture and breast ptosis. An
augmentation mastopexy with fat grafting was performed
after complete capsulectomy and implant removal. (a)
Preoperative frontal view; (b) preoperative oblique view
of the patient; (c) fat grafting injection planning including
cleavage remodeling to reduce the intermammary
distance; (d) postoperative frontal view; (e) postoperative
oblique view of the result
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