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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Keywords:© 2014 by Lippincott Williams & Wilkins
autologous fat injections; breast augmentation