Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_654_Библиотеки_им_академика_М_И_Перельмана
.pdf
9 Transumbilical Breast Augmentation WithSaline andSilicone Implants
https://t.me/medicina_free
123
Fig. 9.25
(continued)
124
https://t.me/medicina_free
G. H. Patino
9.9 Pearls ofWisdoms
• Tumescent anesthesia minimizes the risk of bleeding.
• Implant rupture during insertion is prevented by manual
insertion of the Silicone implants instead of instrument
assisted insertion.
• It is very important to have the Anesthesia Provider para-
lyze the patient at the time of insertion of the Silicone
implants.
• The saline implants can be easily inserted under oral
sedation and the modied Klein tumescent anesthesia
described.
Further Reading
Brennan WA, Haiavy J.Transumbilical breast augmentation: a practical
review of a growing technique. Ann Plast Surg. 2007;59(3):243–9.
Caleel RT.Transumbilical endoscopic breast augmentation: submam-
mary and subpectoral. Plast Reconstr Surg. 2000;106:1177–82.
Dowden RV.Technical update on transumbilical breast augmentation.
Aesthetic Surg J. 2000;22:240–2.
Dowden RV. Dispelling the myths and misconceptions about
transum-umbilical breast augmentation. Plast Reconstr Surg.
2000;106:190–6.
Dowden R.Keeping the transumbilical breast augmentation procedure
safe. Plast Reconstr Surg. 2001;108:1389–400.
Dowden RV. Why the transumbilical breast augmentation is safe for
implants. Plast Reconstr Surg. 2002;109:2576–9.
Dowden RV. Transumbilical breast implant replacement. Aesthetic
Surg J. 2003;23:364–9.
Dowden RV.Transumbilical breast augmentation is safe and effective.
Semin Plast Surg. 2008;22(1):51–9.
Dowden RV, Reisman NR, Gorney M. Going off-label with breast
implants. Plast Reconstr Surg. 2002;110:323–9.
Johnson GW, Christ JE.The endoscopic breast augmentation: the tran-
sumbilical insertion of saline-lled breast implants. Plast Reconstr
Surg. 1993;92:801–8.
Momeni A, Padron NT, Fohn M, et al. Safety, complications, and
satisfaction of patients undergoing submuscular breast augmentation via the inframammary and endoscopic transaxillary approach.
Aesthetic Plast Surg. 2005;29:558–64.
Pound EC III, Pound EC Jr. Transumbilical breast augmentation
(TUBA): patient selection, technique, and clinical experience. Clin
Plast Surg. 2001;28:597–605.
Songcharoen S.Endoscopic transumbilical subglandular augmentation
mammaplasty. Clin Plast Surg. 2002;29:1–13.
Sudarsky L.Experience with transumbilical breast augmentation. Ann
Plast Surg. 2001;46:467–72.
Vila-Rovira R. Breast augmentation by an umbilical approach.
Aesthetic Plast Surg. 1999;23:323–30.
Breast Augmentation: Autologous Fat
https://t.me/medicina_free
Transfer
KristineBrecht
10
10.1 Introduction
Breast enhancement procedures are an important part of
Cosmetic Surgery. The mental and physical well-being from
chest wall enhancement are equally an important component of
the transformation. Fat transfer to the breast is an option for
those who want additional volume with no incisions and less
down time. Fat transfer with additional platelet rich plasma
(PRP) can offer additional benets by making the skin healthier
from the inside out. The additional benet of not having a synthetic product in the body, but rather their own repurposed fat is
an attractive benet. Stitches are not needed, because the incisions are very small. General anesthesia and IV sedation are not
needed. Longevity of fat transfer can be for decades assuming
the transfer of fat was done correctly and the host of the transplant is a good candidate. Fluctuations in size of the transplanted
areas can occur over the years. Fat cells can grow and reduce in
size with weight uctuations. Optimal results and future longevity of fat transfer depends on the physiologic stability of the
patient’s body over the decades. More fat transfer procedures
can be done over time to adapt to these normal physiologic
changes, if a patient prefers (Hoyos 2014; Nahai 2011).
10.2 Success ofFat Transfer totheBreast
10.2.1 The Basics
10.2.1.1 What Is Fat Transfer?
Fat transfer is the harvesting of fat from one part of the body
and injecting it into a different part of the body. The success
of this fat harvest and injection sculpting depends on the
various steps involved in the process.
Supplementary Information The online version contains supplementary
material available at
K. Brecht (*)
St. Annes Hospital, Burien, WA, USA
https://doi.org/10.1007/978- 981- 99- 3726- 4_10.
10.2.1.2 Why Fat Transfer?
Fat transfer during liposuction is essentially unwanted fat
which would have been otherwise discarded but is repurposed and recycled during the same procedure for the same
individual as additional volume in another area of the body.
Incisions for fat transfer are very small, so no stitches are
needed, there are minimal postsurgical restrictions and hence
a faster recovery for the patient.
10.2.1.3 Safety
Fat transfer is safe if done appropriately by a trained surgeon. Understanding the anatomy of the breast and chest
wall is important. In an “awake” patient it is easier to avoid
injuring the musculature and damaging the vasculature,
because patient will feel severe pain when these structures
are injured. Staying in the subcutaneous plane below the skin
and above the pectoralis muscle is imperative to avoid unnecessary complications.
10.2.1.4 Risks andBenets
Like any cosmetic surgical procedure risks are rare with
bleeding and infection being the top two potential risks.
Using tumescent anesthesia and preop antibiotics will have
minimal risks in the hands of a surgeon specializing in fat
transfer.
One hundred percent take of the transplanted fat is not
realistic, and take of the fat is based on multiple factors, but
typically a noticeable long-term augmentation is seen.
Because of the adipocytes ability to be sculpted in place
and its resilience, it can be placed in many locations, and
multiple treatments can be done over time for an additive
result and benets (Shiffman 2010).
Although many innovative efforts to rene the techniques
of fat transfer have been reported, problems such as unpredictability and low retention rates caused by partial necrosis,
remain. Fat retention rates reported in the literature vary
widely, ranging from 30 to 95%. The actual mechanism by
which fat grafts survive post-transfer remains incompletely
understood and is postulated to be one of the following.
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
M. Thomas, J. D‘silva (eds.), Manual of Cosmetic Medicine and Surgery, https://doi.org/10.1007/978-981-99-3726-4_10
125
126
https://t.me/medicina_free
K. Brecht
Cell Survival Theory
It was rst proposed by Peer in the early 1950s (Peer 1950).
According to this theory, fat graft survival depends mainly
on the transfer of viable adipocytes and the establishment of
a blood supply from the recipient site (Fig.10.1). Fat grafts
within only 2mm from the edge of the vascularized tissue
could survive after fat grafting as their initial nutrition is
through serum imbibition through contact with the recipient
tissue bed and reestablishment of the blood supply to the
grafts. This theory emphasizes the need for processing and
injection techniques that minimize trauma, thereby enabling
the transfer of viable adipocytes. Also the technique used for
Fig. 10.1 Schematic diagram
showing that only fat grafts
having well established blood
supply will survive
fat graft should be atraumatic and fat grafts should be placed
in small aliquots during each injection. Multiple passes of
the cannula within multiple tissue tunnels and different
planes should be utilized for injection so that the fat grafts
have maximum contact with recipient site for possible reestablishment of circulation to the grafts (Zhao etal. 2012).
Host Replacement Theory
The host replacement theory suggests that ischemia of fat
grafts causes early death of transferred adipocytes and that
the replacement of these adipocytes is through the activation
and regeneration of ADSCs (Suga et al. 2010) (Fig. 10.2).
Fig. 10.2 Diagram showing
the Adipose derived stem cells
surviving the ischemia,
developing a blood supply
and then getting converted to
adipocytes
10 Breast Augmentation: Autologous Fat Transfer
https://t.me/medicina_free
127
Therefore, the nal volume retention after fat grafting is
largely determined by the rate of successful adipocyte
replacement by ADSCs.
10.2.1.5 Indications ofAutologous Breast
Augmentation
1. For primary breast augmentation patients, who do not
want Implants. Augmentation of the breast is done
sequentially with average increase of one cup size in
every procedure.
2. Secondary fat injection is required in people who have
undergone breast Implant to mask the visible edges of
breast implant or correction of associated wrinkles and
rippling.
3. When patient wants removal of implant and a more natu-
ral breast enlargement. Closing the pocket by sutures followed by fat grafting is usually a good choice for reaching
the patient’s goal.
4. Congenital breast deformity cases with tuberous breast
where release of constricted base and fat injection would
give a nice suitable breast size and shape when implant is
not desired by patient or strictly necessary thanks to
enough breast glandular volume.
5. Breast reconstruction cases that had resultant defect after
lumpectomy or skin sparing mastectomy or breast reduction asymmetry could benet from localized fat injection
to correct contour of breast or recreate the whole breast
when combined with Brava system (Romeo etal. 2016).
10.2.1.6 Contraindications
Contraindication for fat transfer include smokers of nicotine
products, and poorly controlled medical disorders. Patients
with sub-optimally controlled endocrine disorders although
not an absolute contraindication may have a poorer
percentage take of the transferred fat. Immune suppressed
individuals will also have less than optimal fat transfer take.
swelling and mild discomfort, but that is temporary, and is
part of the normal process of recovery. If for any reason the
surgeon believes the patient expectations are unreasonable or
unattainable it is better not to do their surgery.
10.2.3 Pre Op
It is important to give enough time to do the pre-operative
discussion with the patient including: informed consent, history and physical exam, education, prescription for medications, labs, and imaging.
Consent for surgery can be quite lengthy, but must
include informed consent discussing in detail all of the
potential risks and benets of the surgery that they are wanting, pre- operative diagnosis (example: lack of breast volume), a history and physical exam, patient education of
procedure and on all prescription medications. Appropriate
lab works for preop are helpful. Baseline Mammograms for
screening is recommended, otherwise an opt-out consent for
mammogram should be signed by the patient. Fat transfer
does not increase the risk of breast cancer, but in the general
population 1in 8 women will get breast cancer for any reason. Antibiotic, such as Keex or Bactrim, can be taken
from 1 day before the surgery, day of surgery, and for 5 days
post op, for infection prevention. Promethazine is an antinausea medication that will complement the oxycodone.
Promethazine taken with food, 2–3min prior to taking the
oxycodone will help minimize nausea and vomiting.
Gabapentin is an alternative non-narcotic option for neuropathic discomfort. It is important that patients understand
what medications they are being prescribed, including
potential interactions with opioids for pain management.
Prior health medical records, and possibly medical clearance from their primary care providers may be needed if
patients are not baseline healthy, or any questions arise during the consultation and preop work-up.
10.2.2 Preparing forSurgery
10.2.2.1 Discussing Expectations
Expectations of patients must be understood fully because if
their perceived expectations are not met, they will be
unhappy, no matter how good the transformation is from
their baseline. Social media and our culture have evolved
certain expectations that may not be a reality for every individual. Perfection as a goal is a losing battle. We are constantly discussing the concept of enhancing and improvement
as an evolving journey. One and done is not realistic.
Although our transformative surgeries may give signicant
improvement, they are not permanent, as the nature of aging
and gravity are persistent opposing force. Patients must take
an active role in their healing journey. Surgeries do cause
10.2.3.1 Markings
Markings are an essential component of the pre-procedure
evaluation and physical exam, showing where fat will be
suctioned from for harvest to the breast, and markings on the
breast to help understand where you are wanting to place the
fat (Fig.10.3). Markings, however, are usually reserved for
the operative day, before going to the operating room.
Markings should be done in the standing position, as laying
down can change the position of the defects.
10.2.3.2 Photography
Before and after photos taken in different views are essential
for the documentation of recovery and to remind the patients
of their baseline and their amazing transformations
(Fig.10.14).
128
https://t.me/medicina_free
K. Brecht
Fig. 10.3 28 year-old female concerned about the loss of volume in the upper pole of the breast-Preop markings in various views
10 Breast Augmentation: Autologous Fat Transfer
https://t.me/medicina_free
Fig. 10.4 (a) Tools used for
fat transfer. Curved and
straight cannulas. (b) Filters
for micro and nano fat
transfers
a
b
129
Photos are taken prior to marking in order to show all possible skin issues (such as preop scarring, stria, skin color
changes, moles, etc.) present prior to surgery. Asymmetry in
the breasts if any is also documented. A second set of photos
are done “post-marking,” and serve as a good reference during surgery.
10.2.3.3 Anesthesia Options
Breast fat transfer can be done under local anesthesia only,
local with IV sedation or under general anesthesia. The
choice of anesthesia is guided by the comfort level of the
surgeon, pain threshold of the patient, and the comfort level
of the nurse anesthetist and/or anesthesiologist.
10.2.3.4 Tools
Liposuction devices (Fig.10.4a, b).
The choice of the liposuction device in itself is not as
important, as long as the surgeon is comfortable with the
technologies that they have. The ability to ensure a gentle
consistent suctioning and staying below the 450mmHg suctioning pressure is important, in order to prevent the rupture
of the fat cells and damage of the cellular blood supply.
130
ab
https://t.me/medicina_free
K. Brecht
Fat Disruptor Devices
Fat disruptor devices can be of benet with fat harvesting,
staying below 70% power with ultrasonic devices, or gentle
power assisted devices to obtain a consistent size of the individual fat globules, without destroying them, will aid in a
more smooth and consistent fat grafting process. Laser fat
disruption is contraindicated for fat transfer.
10.2.3.5 Fat Transferring Collecting Device/
Set-Up
Fat suctioned must be aspirated into a sterile canister for
retrieval, using the supranatant fat and discarding the infranatant uid (Fig.10.5a, b).
PRP is mixed in with the supranatant fat along with gentamycin antibiotic prior to fat transfer for increased chances of
a successful fat transfer.
PRP (platelet rich plasma) is prepared by drawing the
patients’ blood, spinning it down in a gel tube at 2200–
2500RPM, isolating the top yellow component “PRP” and
mixing with the liposuctioned fat.
Cannula selection for inltration, suctioning, and injecting are an important component to a successful fat transfer
procedure.
Cannulas for inltration of tumescence are of 3 mm or
smaller and are adequate and efcient for delivering the
anesthesia, but still tolerated by the patient who is awake.
Cannulas for suctioning of fat are usually 3–4mm diameter and are an optimal maximum size to minimize the scarring of the skin, and allowing for efcient, effective sized fat
globules for harvesting and then transfer to the breast.
Cannulas for injecting of fat should not be too big or too
small, and aliquots of fat injected in any one spot should not
be too large, optimally not more than 5–10cc of fat should
be injected in an area so as to allow proper grafted fat cell
contact with the native fat cells. This is done using a 60 cc
syringe, without tension and injected in a radial pattern.
Cannulas that have been helpful in my practice are 12g–
20cm straight (2.7mm), and 11g–15 cm curved (2.0mm)
for breast fat transfer procedures.
10.2.4 Procedure
10.2.4.1 Steps ofFat Transfer totheBreast
1. Mark the patient’s breast where the volume is lacking and
shape has to be improved. There are various ways to
undertake the marking of the area (Fig. 10.6a–c).
Primarily the area of deciency has to be marked if the
whole breast does not have to be augmented (Fig.10.6a).
As mentioned before, the marking has to be undertaken in
a standing or sitting position as the breast tends to move
laterally in the lying down position. The track of needles
can be marked as seen in Fig.10.6c, so that a crisscross
pattern of fat grafting is visible.
2. Harvest fat by liposuction
Fat is obtained for fat transfer through liposuction
(Fig. 10.7a). Liposuction using manual devices such as
the tulip technique with be slow and cumbersome for the
hundreds of cc of fat volume that will be needed for a
good voluminous look in bilateral breast fat transfer.
Liposuction with water assisted, power assisted and ultrasound assisted devices (Fig.10.7b) will prove to be the
most effective and efcient technologies for adequate and
from any part of the body can be adequate for fat transfer,
as long as you comply with the suction pressures and
power percentages. Laser assisted liposuction devices are
contraindicated for fat transfer harvest as they will destroy
the fat cells due to the heat generated by the laser
process.
Fig. 10.5 (a, b) Tools used for fat transfer. Fat being collected in the canister. Supernatant fat and infranatant uid being separated for fat transfer
with cannula
ab
10 Breast Augmentation: Autologous Fat Transfer
https://t.me/medicina_free
c
131
Fig. 10.6 (a) Showing deciency of breast volume in the upper outer pole. (b) Uniform breast enlargement is marked as a radial pattern. (c) The
cannula tracks can be marked in the radial pattern as well
3. Prepare fat for injection: The fat is collected in a sterile
container (Gas sterilized) and once adequate volume of
fat has been harvested, it is allowed to stand.
(a) Decant out infranatant uid (Fig.10.8a)
(b) Wash the fat with saline and lter the extra saline
through the sieve (Fig.10.8b)
(c) Centrifuge the fat for 3min if you want concentrated
fat (Fig.10.8c)
(d) Add PRP and/ or Gentamycin if it is your protocol
(Fig.10.8d)
(e) Put fat into 5/10 or 60cc syringes depending on your
4. Anesthesia, positioning of patient and Antibiotic prophylaxis (Kristine and Brecht 2020)
(a) Concentration of tumescence solution: 1 L Normal
Saline, 1000mg of Lidocaine (50cc 2% Lidocaine),
1cc Epinephrine 1:1000, 10cc 8.4%Bicarbonate and
Hyaluronidase 1500IU is mixed as part of the tumescent solution.
Numb the incision site with 1cc tumescence solution, next inltrate the breast with 150–250 cc of
tumescence solution, depending on the baseline
breast size and surface area of the breast.
comfort level and getting it ready for transfer.
132
a
https://t.me/medicina_free
K. Brecht
(c) Safety prophylaxis:
Antibiotics the night before, and an hour before
and post procedure are prophylaxis measures in place
to minimize the risk of infection. With “Cinderella
anesthesia” the procedure of harvesting fat and transplant may take less than 2h, the patient is allowed to
move their legs on the operating room table, so DVT
prophylaxis with compression hose, leg sequential
compression devices and anticoagulants are not necessarily indicated. However, longer procedures under
deeper anesthesia in a patient with risk factors for
b
blood clots may require additional prophylaxis measures. Early ambulation immediately after surgery
and at home with assistance over the next 24–48h is
an important safety measure.
5. Small incisions are made with a scalpel at the outer quadrant and inferior quadrant of each breast (Fig.10.9)
Fat, once adequately harvested by the techniques mentioned above, can be mixed with additional PRP, and then
placed in the breast. Maximum volume of fat to be transferred to each breast can be hundreds of cc per breast
which is only limited by the skin’s tautness and lack of
brous tissue to hold the fat globules. Over ll of fat
results in decreased fat retention due to reduced vascularity hence it is better to undertake the procedure in two
stages at intervals of 3 months with better outcome. Small
Fig. 10.7 (a) Fat harvest from the abdomen using a curved cannula.
(b) Fat harvested using the VASER technology
incisions, not more than a few millimeters are placed at
the upper axillary region and in the inframammary region
to minimize the visualization of the incision once healed,
Tumescent anesthesia has revolutionized surface
surgeries in cosmetic surgery, allowing for better
perioperative and post-operative hemostasis and pain
control, hence minimizing the need for much oral
pain control post procedure. Cinderella AnesthesiaR
patented by Dr. Kristine Brecht, allows for a combination of oral sedation and tumescence to give
anesthesia for the cosmetic procedure, without the
need of oxygen supplementation, IV sedation or
General Anesthesia.
(b) Patient positioning:
For this procedure the patient lies on her back, and
does not need to change position during the procedure. Tumescent anesthesia allows me to make the
patient sit and move her arms as and when required.
Keeping the arms at the side of the torso bilaterally
helps to create an anatomical esthetically pleasing
augmented breast.
but to also allow for adequate cannula placement of the
fat to the breast.
6. Inject fat with a cannula in 5–10cc aliquots.
Five to 10cc aliquots of fat are injected in a radial pat-
tern and placed primarily during withdrawal of the cannula. Fat transfer to specic areas having reduced breast
volume is the objective, but special care should be made
to build a scaffolding of fat from the lower pole of the
breast, building upwards to the superior pole of the breast.
Maximum volume of fat should be placed in the pectoralis fascia and the subcutaneous tissue. As fat is placed the
tissue matrix expands (Fig. 10.10). It is better to work
according to a systematic plan such as inferior pole to
superior pole and deeper to supercial (Fig. 10.11).
Placing fat appropriately will achieve a natural fullness
and more visually appealing cascading of the breast
shape. If possible, fat should not be injected inside the
breast tissue.
Соседние файлы в папке Библиотека им академика М.И. Перельмана