From the Plastic Surgery Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, People’s Republic of China.
Received March 27, 2014, and accepted for publication, after revision, April 24, 2014.
Conflicts of interest and sources of funding: none declared.
Reprints: Fa-Cheng Li, MD, PhD, Plastic Surgery Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Ba-Da-Chu Rd 33, Shi-Jing-Shan District, Beijing 100144, People’s Republic of China. E-mail: firstname.lastname@example.org.
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The number of patients choosing to receive augmented mammaplasty is increasing steadily with rapid economic development in China. Although implantation of breast prosthesis remains the most popular cosmetic breast surgery, a large number of patients completely refused this operation because of their nonacceptance of having artificial materials in body. Concerning adverse effects of postoperation residual scars, contracture deformity, as well as less natural shape and feel in breast augmentation, some other patients turned to breast augmentation with injectable materials. It was estimated that Amazing Gel (polyacrylamide hydrogel) injection, which induced severe complications including breast tissue necrosis and chronic pectoralis inflammation evoked by material infiltration, have been performed in more than 500,000 people. Clinical application use of Amazing Gel was prohibited by Chinese government in April 2006.1
In recent years, autologous fat grafting for breast augmentation showed great outcomes in cosmetic enhancement in size, shape, and texture of breast. Zheng et al,2 Illouz and Sterodimas,3 Coleman and Saboeiro,4 and other authors all reported autologous fat graft as an effective method either for breast reconstruction or cosmetic breast augmentation. Besides, as the traditional aesthetic conception of Chinese tends to mingle with the Western, people admire a figure both plump and slender. Moreover, autologous fat grafting combines liposuction and breast augmentation, so it becomes more and more popular.
This article seeks to present our 8-year clinical experience with autologous fat transplantation for breast augmentation and describe our harvesting and fat processing and transfer techniques, along with review of clinical results of our patients.
PATIENTS AND METHODS
A total of 105 female patients who underwent autologous fat grafting in breast from July 2002 to August 2010 were included in this retrospective study. The age distribution of the patients at the time of the operation ranged from 18 to 45 years, with a mean of 31.3 years. Indications for fat grafting in these patients included micromastia (101 patients), tuberous breast deformity (2 patients), and severe asymmetry (2 patients). All the patients underwent major or mild body contouring at the same time. The study protocol complied with the Declaration of Helsinki and all patients were provided written informed consent. Before operation, breast magnetic resonance imaging (MRI) or x-ray mammography was performed.
Areas for liposuction and breast lipoinjection were marked with the patients in the upright position. Liposuction area included abdomen, flanks, trochanteric region, inner thigh, medial aspect of knees, and upper arms, respectively, depending on the patient’s natural fat distribution. Under general anesthesia, the liposuction area was infiltrated with tumescent solution (20 mL of 2% lidocaine with epinephrine, 1:100,000 per liter of normal saline) following the principles described by Coleman. The fat is aspirated using a 3-holed blunt cannula (3 mm in the inner diameter) connected to a 20-mL syringe. All aspirated fat was collected together within a sterile container with a single-layered cotton gauze in it (Fig. 1). The aspirate was washed 3 to 4 times with 4°C cool normal saline and condensed with dry cotton pad to allow saline, oil, and blood cells to be absorbed. Through the previously mentioned process, 50% to 70% of the liposuction was successfully acquired which contains mainly pure lipoparticle for lipoinjection (Fig. 2).
Before lipoinjection, a tiny incision was made at the lateral region of the inframammary fold. Each breast was infiltrated with tumescent solution in the retroglandular and subcutaneous layer. A 14-gauge, 1-hole blunt cannula was connected to a 20-mL Luer-Lok syringe filled with the processed fat (Fig. 3, left). During the injection, the fat was dispersed evenly into the breast tissue, whereas the cannula was withdrawn in conjunction with slow and steady pressure on the plunger, leaving behind the form of fine noodle-like adipose tissue (Fig. 3, middle). The fat is placed in multiplane from deep to subcutaneous tissue (Fig. 3, right). Approximately two thirds of the collected fat was injected into the retroglandular and intraglandular space layer by layer. The remaining tissue was injected in the subcutaneous space. After injection, the injected area was carefully molded and reshaped to adapt the outline of the desired breast (Fig. 4).
All patients were discharged from the surgery center after recovery from anesthesia and were informed with activity limitation of 3 to 7 days. Local cold compresses were carried out as needed to reduce and prevent secondary injury resulting from edema and inflammation. The patient was instructed not to compress or massage the breasts within the duration of 3 months after surgery.
The clinical outcomes were evaluated according to the methods described by Zheng et al2 at 6 months after the last fat grafting. In brief, the results were graded based on the improvement of breast augmentation and correction of contour defect. Fifteen patients who received a second or third fat grafting were examined by MRI of breast to evaluate survival of injected fat as well as potential lump formation. Clinical data relating to any complications, especially the development of breast lump that can be palpated, were collected during follow-ups in all patients.
Among all patients in the present study, 80 patients received 1 session of fat grafting, 20 patients received 2 sessions of fat grafting, and 5 patients received 3 session of fat grafting. An average of 205 mL of fat was transplanted at each session per breast (range, 120–250 mL). The average clinical follow-up was 18 months (range, 6–72 months). Of a total of 105 patients, 47 (44.8%) were evaluated as significantly improved (Figs. 5–7), 41 (39.0%) as improved, and 17 (16.2%) as not improved. There was no evidence of newly occurring oil cyst, fat necrosis, or breast masses seen in the postoperative MRI scan. Two patients developed benign-appearing calcifications easily distinguishable from cancer. Three patients developed small nodules that revealed fat necrosis on aspiration (Figs. 8 and 9).
In the present study, we found that outcomes for breast augmentation correlated well with the total amount of injected fat. If the volume of the fat transplanted into the breast is less than 150 mL on each side, the result of augmentation is less obvious. Among all patients treated in this study, no cosmetic improvement was noticed in 17 (16.2%) thin patients who had been injected less than 150 mL of fat because no more adipose deposit was suitable for harvesting. Therefore, in our opinion, autologous fat transfer for breast augmentation is not suitable for thin women who have insufficient fat deposit. Significant cosmetic improvement was achieved through 2 or 3 sessions of fat grafting in patients with adequate adipose deposit even if their breasts are very small (Fig. 7). Interestingly, we found out that when patients received a second fat graft, the cosmetic result would be enhanced significantly. This may be attributed to the increased vascularization that resulted from survival of previously transplanted fat.
Although various preparation techniques have been suggested for improving survival of fat grafts,5–7 including centrifugation,8–12 simple decantation,13 vigorous washing,14 no washing at all,15 and dense-cloth fat concentration,16 there is still controversy about their long-term results. Coleman8 stressed the importance of removing nonviable fat aspirate components such as oil, blood, and lidocaine by centrifugation. He reports high physician and patient satisfaction from his “structural fat grafting” technique. This method has gained widespread clinical application and has become fundamental to many techniques described in numerous reports. However, centrifugation was challenged by Rohrich et al,17 who found that fat survival rate from centrifugation showed no better than that of filtration. Ramon et al18 compared samples prepared either via centrifugation or cotton towel drying in a nude mouse model, and observed no differences in fat weight or volume, yet the towel separated samples exhibited decreased fibrosis on histologic analysis.
Khater et al,19 in a clinical and experimental study, presented their experience with the following 2 different techniques of fat processing: centrifugation and serum washing. The authors concluded that in noncentrifuged adipose tissue, more active preadipocytes were maintained, which could possibly lead to enhanced survival of injected fat.
In a clinical trial, Botti et al demonstrated that there was no significant difference of survival between washed and centrifuged fat. They, thus, went back to use the simple filtered fat after some years of using centrifuged fat.20
The processing procedure we used to prepare fat for injection is similar to the method described by Kuran and Tumerdem.21 It is simple, safe, and effective. The aspirate was cleansed of blood, oil, and lidocaine by filtering after the gentle washing with cool 0.9% normal saline (Fig. 1). According to the study by Condé-Green et al,13 the aspirate processed by washing not only maintained considerable number of adipocyte with good integrity deprived of blood cell contaminants but also preserved a great number of endothelial and mesenchymal stem cells, which are believed to contribute to increased neoangiogenesis, reduced apoptosis, and promotion of adipocyte differentiation.22 After filtering, there is still a lot of water and oil in the fat. Del Vecchio and Rohrich find that after sedimentation and discarding unwanted crystalloid, there is still 20% to 30% of additional crystalloid in the fat. Ignoring the step of condensation reduces long-term volume maintenance, there is a “percentage yield” by 20% to 30% before the procedure is finished than condensation method.23 Thus, through the process of gauze filtering, cool saline washing, and cotton pad concentrating, the desired pure semisolid fat was achieved for further injection (Fig. 2).
Time efficiency (optimization) versus effectiveness of technique (maximization) is a critical workflow concept in fat transplantation.23 The method we used is associated with a Chinese traditional philosophy—the “Golden mean,” which means we must achieve the best balance between minimal injury and less ischemic time of the fat before it is transplanted into the breast. It is reported that most of adipocytes in aspirate preserved at room temperature beyond 4°C experienced significant damage. The lipotransfer should be performed as quickly as possible after aspiration.24
Using smaller syringes (10 mL) with minimal negative pressure is considered as a standardized technique for harvesting of fat.25,26 However, this technique is time consuming for collecting large volume of fat for grafting. Therefore, a 20-mL syringe was used in the present study for fat harvesting in an effort to reduce the time consumed in the whole surgery.
Grafted fat that is too large in volume for injection may suffer central necrosis in vivo because of a lack of both adequate nutrition diffusion and neoangiogenesis. Minimizing the amount of fat grafted with each pass of cannula during injection will maximize the surface area of contact between the grafted fat and recipient tissue. Coleman’s technique of fat grafting has been popularized and known to many surgeons, which emphasizes on atraumatic method of fat harvesting, proper centrifugation, and miniscule injection aimed at maximal contact between transplanted fat and recipient tissue, but it took approximately 3 hours to place 250 mL into an individual breast.4 The negative effects of extracorporeal ischemic time potentially outweigh the benefit of the technique of minimal trauma to fat for injection. To enhance the efficiency of fat injection while reducing the ischemic time, we used a 20-mL Luer-Lok syringe for fat injection in which injection of 20 mL of fat contained in 1 syringe can be completely fulfilled in 1 minute.
Remarkable, long-lasting, and natural improvements of breast size and shape are achieved with autologous fat grafting in most patients in the present study. The more details you pay during the process of the procedure, the better clinical outcomes you will get. The details in the duration of breast augmentation including low pressure but efficient technique of harvesting of fat, condensation with cotton pad after gentle washing and filtering, multilayered deposition of fat, and decrease of ischemic time are discussed in the study.
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