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Brava and Autologous Fat Transfer Is a Safe and Effective Breast Augmentation Alternative

Results of a 6-Year, 81-Patient, Prospective Multicenter Study

Herold, Christian M.D.; Ueberreiter, Klaus M.D.; Vogt, Peter M. M.D.

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Plastic and Reconstructive Surgery: September 2012 - Volume 130 - Issue 3 - p 479e-480e
doi: 10.1097/PRS.0b013e31825dc45b
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We read with great interest the article entitled “Brava and Autologous Fat Transfer Is a Safe and Effective Breast Augmentation Alternative: Results of a 6-Year, 81-Patient, Prospective Multicenter Study” by Khouri et al.1 It is significant that the additional application of the Brava device, though it is more expensive and somewhat elaborate for the patients, is able to produce superior postoperative results in comparison with all other techniques of autologous fat transplantation until now.

We have to congratulate the authors for their decision to use magnetic resonance imaging volumetry2 for qualitative and quantitative progress control after autologous fat transplantation as we propounded some time ago.3 This volumetric tool has been proved to be very exact and reproducible4 and even offers the possibility of examining different injection planes.5 As in autologous fat transplantation to the breast, part of the injected fat is placed in the pectoral muscles; we have described a protocol for magnetic resonance imaging volumetry with a region of interest in the area between the skin and the thoracic wall, including the pectoral muscles. The midsternal line is the border between both sides and the lateral thoracic artery bilaterally is the lateral border.4

The studies cited in the work by Khouri et al. that compare the results of autologous fat transplantation to the breast in combination with the Brava system to results without external expansion are worth looking at more thoroughly. In the study by Wang et al., sonography-based volumetry was performed 1 month after fat transplantation.6 In the study by Zocchi and Zuliani, no information is given regarding how the volume of fat survival was analyzed.7 The rate of fat survival in the study by Delay et al. is simply assumed by clinical examination.8 Yoshimura et al. performed magnetic resonance imaging–based controls to analyze complications, but volume survival was analyzed by three-dimensional surface imaging.9

After all, there are only four studies in the literature with qualitative and quantitative progress control based on magnetic resonance imaging examinations after autologous fat transplantation to the breast. The study by Khouri et al. reported a yield of 82 ± 18 percent, and a study by Alexander Del Vechio and Bucky,10 who also used the Brava system in 25 patients, reported a volume survival of 64 ± 13 percent. These results have to be compared with the results after fat transplantation with the BEAULI technique.11 Results have been published in 2010, with a volume survival of 72 ± 11 percent in the first 10 patients4 and a survival rate of 76 ± 11 percent in a later, larger cohort of 36 patients.11 It has to be noted that the plain adipose phase was calculated, as the BEAULI technique does not use centrifugation, as performed in the protocols combined with the Brava system described by Alexander Del Vecchio and Bucky10 and Khouri et al.1

Finally, the discussion about different techniques has entered a level at which it is based on reliable volumetric analysis and not on very subjective clinical analyses by the surgeon, who would definitely not underrate the results of his or her work. We look forward to seeing the results of other techniques and are delighted to have learned about the potential of “preparing the land before seeding” with the Brava system as has been comprehensively demonstrated in the discussed work.

Christian Herold, M.D.

Department of Plastic, Hand, and Reconstructive Surgery, Hannover Medical School, Hannover, Germany

Klaus Ueberreiter, M.D.

Department of Plastic Surgery, Asklepios Klinik, Birkenwerder, Germany

Peter M. Vogt, M.D.

Department of Plastic, Hand, and Reconstructive Surgery, Hannover Medical School, Hannover, Germany


The authors have no financial interest to declare in relation to the content of this communication. Dr. Ueberreiter is a shareholder of Human Med and coinventor of the Lipocollector (not discussed in this letter or in the article). Travel expenses for several conferences were covered by Human Med.


1. Khouri RK, Eisenmann-Klein M, Cardoso E, et al.. Brava and autologous fat transfer is a safe and effective breast augmentation alternative: Results of a 6-year, 81-patient, prospective multicenter study. Plast Reconstr Surg. 2012;129:1173–1187.
2. Herold C, Knobloch K, Stieglitz LH, Samli A, Vogt PM. Magnetic resonance imaging-based breast volumetry in breast surgery: A transfer from neurosurgery. Plast Reconstr Surg. 2010;125:17e–19e.
3. Herold C, Knobloch K, Rennekampff HO, Ueberreiter K, Vogt PM. Magnetic resonance imaging-based progress control after autologous fat transplantation. Plast Reconstr Surg. 2010;126:260e–261e.
4. Herold C, Ueberreiter K, Cromme F, Busche MN, Vogt PM. The use of mamma MRI volumetry to evaluate the rate of fat survival after autologous lipotransfer (in German). Handchir Mikrochir Plast Chir. 2010;42:129–134.
5. Herold C, Ueberreiter K, Cromme F, Grimme M, Vogt PM. Is there a need for intrapectoral injection in autologous fat transplantation to the breast? An MRI volumetric study (in German). Handchir Mikrochir Plast Chir. 2011;43:119–124.
6. Wang H, Jiang Y, Meng H, Yu Y, Qi K. Sonographic assessment on breast augmentation after autologous fat graft. Plast Reconstr Surg. 2008;122:36e–38e.
7. Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg. 2008;32:313–328.
8. Delay E, Garson S, Tousson G, Sinna R. Fat injection to the breast: Technique, results, and indications based on 880 procedures over 10 years. Aesthet Surg J. 2009;29:360–376.
9. Yoshimura K, Asano Y, Aoi N, et al.. Progenitor-enriched adipose tissue transplantation as rescue for breast implant complications. Breast J. 2010;16:169–175.
10. Alexander Del Vecchio D, Bucky LP. Breast augmentation using pre-expansion and autologous fat transplantation: A clinical radiological study. Plast Reconstr Surg. (in press).
11. Ueberreiter K, von Finckenstein JG, Cromme F, Herold C, Tanzella U, Vogt PM. BEAULI: A new and easy method for large-volume fat grafts (in German). Handchir Mikrochir Plast Chir. 2010;42:379–385.


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