Implants stretch tissue. Removing the implants leaves behind some tissue laxity that can make room for more graft. Removing the implant and fat grafting in the same session has many advantages. The cavity left behind by the implant allows the surgeon to precisely graft the immediate subcapsular plane by digitally controlling the cannula tip. This plane is an ideal recipient and can bulge inward to obliterate the cavity. Immediately after implant removal, tissues are lax and maximally compliant to accommodate the added fat. Over time, this compliance dissipates. If the implant is removed and the cavity is left empty, the excess skin might fold over to create deep wrinkles. Deep surface wrinkles are difficult to correct. For all of these reasons, we highly recommend performing implant removal and fat grafting in the same operation.
In implant-to-fat conversion, the order of operations is crucial. First, graft the immediate subdermal plane surrounding the implant. Keeping the implant in this first step maintains the tissue stretched taut for smoother cannula excursions. Second, remove the implant through a lateral thoracic incision. Reopening the original implant incision will preclude grafting across this scar and will further depress it. Third, graft the subcapsular plane with a finger inside the cavity guiding the cannula. If the implant is subglandular, carefully graft the posterior muscle. Fourth, without creating a cavity, expand the intermediate plane by mesh-releasing the taut vertical fibers that prevent swelling while preserving the loose horizontal fibers of the recipient scaffold. Inject the fat into the potential space of this intermediate plane.
Implant-to-fat conversion is the lowest hanging fruit for autologous fat transfer to the breast and is probably the best solution to implant problems (Figs. 9 through 11). (See Video, Supplemental Digital Content 9, which displays details of implant-to-fat conversion, part 1. First, inject an even 3-mm layer of graft in the immediate subcutaneous plane while it is still stretched taut by the implant. Next, remove the implant through an extramammary incision and inject another thin layer in the immediate subcapsular plane with a finger inside the cavity to guide the cannula and prevent intracapsular injections. Third, though multiple passes of the cannula, release the vertical fibers to mesh-expand the intervening plane and recreate the breast mound. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/C305. See Video, Supplemental Digital Content 10, which displays implant-to-fat conversion, part 2. Grafting the deeper planes after implant removal is a two-handed procedure. Injecting the graft and refilling the plunger is done with the dominant hand while the nondominant hand guides the cannula from the inside of the cavity. A two-way valve makes this motion practical to achieve. A dilute lipoaspirate is preferred, as it places the vertical fibers under tension to facilitate their release with the spatulated tip of the grafting cannula. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/C306. See Video, Supplemental Digital Content 11, which displays implant-to-fat conversion, part 3. Replacing implants with the patient’s own fat is the answer to many of the implant problems and is the low-hanging fruit for autologous fat transfer to the breast. Autologous fat transfer can plump up the laxity left behind after implant removal, and the reverse abdominoplasty and fat transfer purse-string procedure can recruit an additional 100 ml of perimammary tissue, collapse the implant cavity, define the breast folds, and mushroom up a breast mound. With proper technique, much of the implant volume can be replaced with fat. With the reverse autologous fat transfer addition, the resultant breast is slightly smaller but much more natural appearing. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/C307.)
Buttock augmentation with autologous fat transfer is a well-established procedure. The much larger buttocks can accommodate much more graft than the breasts.54 Fat necrosis and oil cysts are also much less of a problem in the buttocks. Furthermore, even without grafting, liposuction of the flanks, thighs, and waists improves the contour of the buttocks. Fatal fat emboli have occurred from inadvertent bolus injections in the large gluteal vein plexus. The best way to prevent this is to follow the principles of injection grafting described earlier under Sowing: Graft Delivery (refer to Table 2).
Fat is the soft-tissue alternative to fibrous scar. Judicious lipofilling turns the fibrous scar into a recipient matrix. What was once a dense fibrous scar becomes the loose supporting fibrous scaffold for fat grafts. The cicatrix-to-matrix concept explains how autologous fat transfer can turn tight and stiff into loose and soft.
Percutaneous aponeurotomy and lipofilling (PALF) has emerged as a regenerative alternative to flap surgery for treatment of scar contractures.52 Percutaneously meshing the restrictive scar and expanding the resultant microcavities with fat injection expands the cicatrix into a fat-filled matrix. For proper three-dimensional release, nicks must be staggered in multiple planes in multiple directions wherever restrictive fibers prevent expansion. We named the technique “Rigottomy” after its originator. This percutaneous meshing expands the restrictive block of scar tissue to create a larger three-dimensional recipient scaffold for autologous fat transfer. The loosened grafted scar becomes softer and closer to the normal surrounding fat tissue. Repeating the process a few months later leads to substantial tissue volume gain and can eliminate the scar to replace it with normal fat. The Rigottomy is useful when grafting fat into scarred tissue to correct a volume deficiency. It transforms a restrictive cicatrix into a regenerative matrix.13,46 (See Video, Supplemental Digital Content 12, which displays PALF. PALF is the regenerative alternative to flaps. Flaps are needed when primary defect reconstruction is not possible. However, as an alternative, we can place the tissues around the defect under tension and inflict a pattern of alternating staggered slits that mesh-expand these tissues. The pattern of slits is performed with a needle that leaves no cutaneous scar, and the slit gaps can be seeded with autologous fat transfer to regenerate the defect. Tissues can regenerate across only very small gaps, and fat grafts require high graft-to-recipient interface, and thus it is important to avoid excessive meshing that creates larger cavities that will result in scar and fat necrosis. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/C308.)
Radiation kills cancer cells but also kills the adipose-derived stem cells responsible for tissue upkeep and for engraftment capacity. Liposuctioned fat is rich in adipose-derived stem cells. Although initially poor to engraft because of the hostile environment, the little graft that takes in the first round makes it easier for more to engraft in the second round. From there on, the advantage is exponential, with more grafting rendering the tissue richer in normal cells and more like nonirradiated tissue. Rigotti made the seminal observation that fat grafting can reverse radiation damage; this has opened the field of radiation damage reversal with autologous fat transfer.18 Autologous fat transfer is best immediately after radiation treatment while the tissues are still inflamed and before fibrosis sets in; it tends to soothe the inflammation and reduce the fibrosis.46
Needles preferentially cut tensed fibers while leaving intact the looser structures. Forceful digital extension tenses the Dupuytren cords before healthy neurovascular structures become tight. (See Video, Supplemental Digital Content 13, which shows how tension is the key to the safe percutaneous release of contracture. This video demonstrates how a needle cuts the tight violin strings but not the looser string. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/C309. See Video, Supplemental Digital Content 14, which displays how release of the Dupuytren contracture with percutaneous aponeurotomy and lipofilling is a minimally invasive regenerative alternative to flaps and extirpative surgery. The key to the procedure is a strong digital extension retractor that places the restrictive fibers under tension. The selective cutting of a needle for structures under tension divides the Dupuytren fibers that prevent extension while preserving the neurovascular bundles. The procedure is safe and particularly suited for multidigit contractures. Lipofilling the meshed cord treats the subcutaneous atrophy and helps prevent recurrence of the fibrosis. This video is available in the “Related Videos” section of the full-text article on PRSJournal.com or at http://links.lww.com/PRS/C310.) Steadily applied strong extension allows needles to cut these restrictive fibers and avoid damage to the neurovascular structures. Multiple percutaneous aponeurotomies mesh-expand the fibrous cord and turn it into a recipient for fat.55 Furthermore, abdominal fat has been shown to be inhibitory to Dupuytren fibroblasts.56 A randomized controlled trial demonstrated that percutaneous aponeurotomy and lipofilling performed at least as well as the standard limited fasciectomy and had faster recovery and less morbidity.57 Percutaneous aponeurotomy and lipofilling can also replace flaps in releasing traumatic scar contractures (Fig. 12).
Magalon et al. and Sautereau et al. found that subcutaneous perioral microfat injection in patients with systemic sclerosis is beneficial in the treatment of facial handicap, skin sclerosis, mouth opening limitation, sicca syndrome, and facial pain.21,22 Effects on scleroderma of the hand are also impressive.
Facial rejuvenation often requires a face fill along with the face lift. In contrast to the large volumes required for body contour, a thin layer of strategically placed fat can yield impressive results. The thin graft layer has an excellent graft-to-recipient interface, resulting in excellent survival. This is where compacted, centrifuged fat might be more advantageous than the loose slurry preferred in large-volume grafting. Autologous fat transfer is the preferred treatment alternative for Romberg syndrome, facial lipodystrophy, and posttraumatic craniofacial defects.58–60
Fat grafting has valuable trophic effects on the recipient tissues. It has been shown to increase dermal thickness and elasticity.17 Interestingly, adipose-derived stem cell supplements did not increase the effectiveness of simple fat grafting. For still poorly understood reasons, fat grafting also has a beneficial effect on neuroma pain and on nerve regeneration. Fat grafting improves the symptoms of Raynaud phenomenon.61 Early phase I clinical trials have demonstrated safety and potential efficacy for adipose-derived stem cells in the treatment of arthritis62 and postprostatectomy erectile dysfunction,63 but larger clinical studies are needed. There are also reports of a beneficial effect on chronic wounds, which might be attributable to the antifibrotic and angiogenic effect of fat grafts.64
Although fat grafting has great therapeutic potential for a growing number of conditions, the risks and concerns must also be addressed. The most commonly expressed concern regarding fat grafting the breast is oncologic risk. However, many studies have failed to show any increased risk.46,65–70 Another commonly expressed concern regarding fat grafting the breast is difficulty in distinguishing fat necrosis from potentially malignant lesions on mammography. However, Rubin showed that the calcifications from fat grafting were less problematic than the calcification from the well-accepted breast-reduction procedures.71 The most well-established serious risk from fat grafting is embolization causing fatal pulmonary emboli, strokes or blindness. This occurs from inadvertently injecting large boluses of fat into veins, most commonly the large gluteal plexus. The best way to prevent this is to follow the principles of injection grafting described earlier under Sowing: Graft Delivery. Even if a vein is inadvertently cannulated, delivering a fraction of a microribbon will not cause significant morbidity.
The applications above show that we not only enlarge soft tissues with autologous fat transfer but—as we enlarge the scaffold with external volume expansion, reorient its fibers, and mesh-expand them—also reshape the tissues. Fat can be seen as the epoxy glue that permeates and cements the modified supportive fibrovascular structure. A conforming adhesive splint that holds the construct in place until it cures completes our ability to mold tissue and to become true “plastic” surgeons (Fig. 13).
Autologous fat transfer is a safe, reliable, and efficacious procedure for many common clinical conditions. With the principles and techniques of fat grafting well established, scientists and clinicians will need to more thoroughly investigate the indications in question and better translate the basic science research into the clinical setting.
1. Lantieri LA, Ozbek MR, Deune EG, et al. Prevention of microvascular thrombosis by topical application of recombinant tissue factor pathway inhibitor. Plast Reconstr Surg. 1996;97:587594.
2. Khouri RK, Sherman R, Buncke HJ, et al. A phase II trial of intraluminal irrigation with recombinant human tissue factor pathway inhibitor to prevent thrombosis in free flap surgery. Plast Reconstr Surg. 2001;107:408415; discussion 416–418.
3. Khouri RK. Avoiding free flap failure. Clin Plast Surg. 1992;19:773781.
4. Khouri RK Jr, Biggs TM. Fat grafting & the philosopher’s stone. J Plast Reconstr Aesthet Surg. 2016;69:e17e18.
5. Khouri RK Jr, Khouri RK. Commentary on: Prospective 1-year follow-up study of breast augmentation by cell-assisted lipotransfer. Aesthet Surg J. 2016;36:191192.
6. Cleveland EC, Albano NJ, Hazen A. Roll, spin, wash, or filter? Processing of lipoaspirate for autologous fat grafting: An updated, evidence-based review of the literature. Plast Reconstr Surg. 2015;136:706713.
7. Gupta R, Brace M, Taylor SM, Bezuhly M, Hong P. In search of the optimal processing technique for fat grafting. J Craniofac Surg. 2015;26:9499.
8. Gabriel A, Champaneria MC, Maxwell GP. Fat grafting and breast reconstruction: Tips for ensuring predictability. Gland Surg. 2015;4:232243.
9. Strong AL, Cederna PS, Rubin JP, Coleman SR, Levi B. The current state of fat grafting: A review of harvesting, processing, and injection techniques. Plast Reconstr Surg. 2015;136:897912.
10. Tocco I, Widgerow AD, Lalezari S, Banyard D, Shaterian A, Evans GR. Lipotransfer: The potential from bench to bedside. Ann Plast Surg. 2014;72:599609.
11. Ross RJ, Shayan R, Mutimer KL, Ashton MW. Autologous fat grafting: Current state of the art and critical review. Ann Plast Surg. 2014;73:352357.
12. Khouri RK, Rigotti G, Cardoso E, Khouri RK Jr, Biggs TM. Megavolume autologous fat transfer: Part I. Theory and principles. Plast Reconstr Surg. 2014;133:550557.
13. Khouri RK, Rigotti G, Cardoso E, Khouri RK, Biggs TM. Megavolume autologous fat transfer: Part II. Practice and techniques. Plast Reconstr Surg. 2014;133:13691377.
14. Yoshimura K. Shiffman M. Cell-assisted lipotransfer for breast augmentation: Grafting of progenitor-enriched fat tissue. In: Autologous fat transfer. 2010.Springer: Berlin, Heidelberg.
15. Rubina K, Kalinina N, Efimenko A, et al. Adipose stromal cells stimulate angiogenesis via promoting progenitor cell differentiation, secretion of angiogenic factors, and enhancing vessel maturation. Tissue Eng Part A 2009;15:20392050.
16. Walocko FM, Khouri RK Jr, Urbanchek MG, Levi B, Cederna PS. The potential roles for adipose tissue in peripheral nerve regeneration. Microsurgery 2016;36:8188.
17. Charles-de-Sá L, Gontijo-de-Amorim NF, Maeda Takiya C, et al. Antiaging treatment of the facial skin by fat graft and adipose-derived stem cells. Plast Reconstr Surg. 2015;135:9991009.
18. Rigotti G, Marchi A, Galiè M, et al. Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing process mediated by adipose-derived adult stem cells. Plast Reconstr Surg. 2007;119:14091422; discussion 1423–1424.
19. Sun W, Ni X, Sun S, et al. Adipose-derived stem cells alleviate radiation-induced muscular fibrosis by suppressing the expression of TGF-β1. Stem Cells Int. 2016;2016:5638204.
20. Yun IS, Jeon YR, Lee WJ, et al. Effect of human adipose derived stem cells on scar formation and remodeling in a pig model: A pilot study. Dermatol Surg. 2012;38:16781688.
21. Magalon G, Daumas A, Sautereau N, Magalon J, Sabatier F, Granel B. Regenerative approach to scleroderma with fat grafting. Clin Plast Surg. 2015;42:353364, viii.
22. Sautereau N, Daumas A, Truillet R, et al. Efficacy of autologous microfat graft on facial handicap in systemic sclerosis patients. Plast Reconstr Surg Glob Open 2016;4:e660.
23. Castiglione F, Hedlund P, Van der Aa F, et al. Intratunical injection of human adipose tissue-derived stem cells prevents fibrosis and is associated with improved erectile function in a rat model of Peyronie’s disease. Eur Urol. 2013;63:551560.
24. Castiglione F, Dewulf K, Hakim L, et al. Adipose-derived stem cells counteract urethral stricture formation in rats. Eur Urol. 2016;70:10321041.
25. Zhao W, Zhang C, Jin C, et al. Periurethral injection of autologous adipose-derived stem cells with controlled-release nerve growth factor for the treatment of stress urinary incontinence in a rat model. Eur Urol. 2011;59:155163.
26. Lopez-Santalla M, Menta R, Mancheño-Corvo P, et al. Adipose-derived mesenchymal stromal cells modulate experimental autoimmune arthritis by inducing an early regulatory innate cell signature. Immun Inflamm Dis. 2016;4:213224.
27. Wu L, Cai X, Zhang S, Karperien M, Lin Y. Regeneration of articular cartilage by adipose tissue derived mesenchymal stem cells: Perspectives from stem cell biology and molecular medicine. J Cell Physiol. 2013;228:938944.
28. Eto H, Kato H, Suga H, et al. The fate of adipocytes after nonvascularized fat grafting: Evidence of early death and replacement of adipocytes. Plast Reconstr Surg. 2012;129:10811092.
29. Kato H, Mineda K, Eto H, et al. Degeneration, regeneration, and cicatrization after fat grafting: Dynamic total tissue remodeling during the first 3 months. Plast Reconstr Surg. 2014;133:303e313e.
30. Khouri RK Jr, Khouri RE, Lujan-Hernandez JR, Khouri KR, Lancerotto L, Orgill DP. Diffusion and perfusion: The keys to fat grafting. Plast Reconstr Surg Glob Open 2014;2:e220.
31. Khouri RK, Khouri RK. Percentage augmentation: The more meaningful index of success in fat grafting. Plast Reconstr Surg. 2015;135:933e935e.
32. Kølle SF, Fischer-Nielsen A, Mathiasen AB, et al. Enrichment of autologous fat grafts with ex-vivo expanded adipose tissue-derived stem cells for graft survival: A randomised placebo-controlled trial. Lancet 2013;382:11131120.
33. Marks PW, Witten CM, Califf RM. Clarifying stem-cell therapy’s benefits and risks. N Engl J Med. 2017;376:10071009.
35. Pietramaggiori G, Liu P, Scherer SS, et al. Tensile forces stimulate vascular remodeling and epidermal cell proliferation in living skin. Ann Surg. 2007;246:896902.
36. Chin MS, Ogawa R, Lancerotto L, et al. In vivo acceleration of skin growth using a servo-controlled stretching device. Tissue Eng Part C Methods 2010;16:397405.
37. Heit YI, Lancerotto L, Mesteri I, et al. External volume expansion increases subcutaneous thickness, cell proliferation, and vascular remodeling in a murine model. Plast Reconstr Surg. 2012;130:541547.
38. Lancerotto L, Chin MS, Freniere B, et al. Mechanisms of action of external volume expansion devices. Plast Reconstr Surg. 2013;132:569578.
39. Chin MS, Lujan-Hernandez J, Babchenko O, et al. External volume expansion in irradiated tissue: Effects on the recipient site. Plast Reconstr Surg. 2016;137:799e807e.
40. Myung Y, Kwon H, Pak C, Lee H, Jeong JH, Heo CY. Radiographic evaluation of vessel count and density with quantitative magnetic resonance imaging during external breast expansion in Asian women: A prospective clinical trial. J Plast Reconstr Aesthet Surg. 2016;69:15881597.
41. Lujan-Hernandez J, Lancerotto L, Nabzdyk C, et al. Induction of adipogenesis by external volume expansion. Plast Reconstr Surg. 2016;137:122131.
42. Khouri RK, Schlenz I, Murphy BJ, Baker TJ. Nonsurgical breast enlargement using an external soft-tissue expansion system. Plast Reconstr Surg. 2000;105:25002512; discussion 2512–2514.
43. Khouri R, Del Vecchio D. Breast reconstruction and augmentation using pre-expansion and autologous fat transplantation. Clin Plast Surg. 2009;36:269280, viii.
44. 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;129:11731187.
45. Khouri RK, Khouri RK, Rigotti G, et al. Aesthetic applications of Brava-assisted megavolume fat grafting to the breasts: A 9-year, 476-patient, multicenter experience. Plast Reconstr Surg. 2014;133:796807; discussion 808–809.
46. Khouri RK, Rigotti G, Khouri RK Jr, et al. Tissue-engineered breast reconstruction with Brava-assisted fat grafting: A 7-year, 488-patient, multicenter experience. Plast Reconstr Surg. 2015;135:643658.
47. Del Vecchio DA, Bucky LP. Breast augmentation using preexpansion and autologous fat transplantation: A clinical radiographic study. Plast Reconstr Surg. 2011;127:24412450.
48. Spear SL, Pittman T. A prospective study on lipoaugmentation of the breast. Aesthet Surg J. 2014;34:400408.
49. Peltoniemi HH, Salmi A, Miettinen S, et al. Stem cell enrichment does not warrant a higher graft survival in lipofilling of the breast: A prospective comparative study. J Plast Reconstr Aesthet Surg. 2013;66:14941503.
50. Wang L, Luo X, Lu Y, Fan ZH, Hu X. Is the resorption of grafted fat reduced in cell-assisted lipotransfer for breast augmentation? Ann Plast Surg. 2015;75:128134.
51. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg. 1997;24:347367.
52. Khouri RK, Smit JM, Cardoso E, et al. Percutaneous aponeurotomy and lipofilling: A regenerative alternative to flap reconstruction? Plast Reconstr Surg. 2013;132:12801290.
54. Rosique RG, Rosique MJ, De Moraes CG. Gluteoplasty with autologous fat tissue: Experience with 106 consecutive cases. Plast Reconstr Surg. 2015;135:13811389.
55. Hovius SE, Kan HJ, Verhoekx JS, Khouri RK. Percutaneous aponeurotomy and lipofilling (PALF): A regenerative approach to Dupuytren contracture. Clin Plast Surg. 2015;42:375381, ix.
56. Verhoekx JS, Mudera V, Walbeehm ET, Hovius SE. Adipose-derived stem cells inhibit the contractile myofibroblast in Dupuytren’s disease. Plast Reconstr Surg. 2013;132:11391148.
57. Kan HJ, Selles RW, van Nieuwenhoven CA, Zhou C, Khouri RK, Hovius SE. Percutaneous aponeurotomy and lipofilling (PALF) versus limited fasciectomy in patients with primary Dupuytren’s contracture: A prospective, randomized, controlled trial. Plast Reconstr Surg. 2016;137:18001812.
58. Jianhui Z, Chenggang Y, Binglun L, et al. Autologous fat graft and bone marrow-derived mesenchymal stem cells assisted fat graft for treatment of Parry-Romberg syndrome. Ann Plast Surg. 2014;73(Suppl 1):S99S103.
59. Fontdevila J, Serra-Renom JM, Raigosa M, et al. Assessing the long-term viability of facial fat grafts: An objective measure using computed tomography. Aesthet Surg J. 2008;28:380386.
60. Pezeshk RA, Stark RY, Small KH, Unger JG, Rohrich RJ. Role of autologous fat transfer to the superficial fat compartments for perioral rejuvenation. Plast Reconstr Surg. 2015;136:301e309e.
61. Bank J, Fuller SM, Henry GI, Zachary LS. Fat grafting to the hand in patients with Raynaud phenomenon: A novel therapeutic modality. Plast Reconstr Surg. 2014;133:11091118.
62. Pers YM, Rackwitz L, Ferreira R, et al.; ADIPOA Consortium. Adipose mesenchymal stromal cell-based therapy for severe osteoarthritis of the knee: A phase I dose-escalation trial. Stem Cells Transl Med. 2016;5:847856.
63. Haahr MK, Jensen CH, Toyserkani NM, et al. Safety and potential effect of a single intracavernous injection of autologous adipose-derived regenerative cells in patients with erectile dysfunction following radical prostatectomy: An open-label phase I clinical trial. EBioMedicine 2016;5:204210.
64. Condé-Green A, Marano AA, Lee ES, et al. Fat grafting and adipose-derived regenerative cells in burn wound healing and scarring: A systematic review of the literature. Plast Reconstr Surg. 2016;137:302312.
65. Rigotti G, Marchi A, Stringhini P, et al. Determining the oncological risk of autologous lipoaspirate grafting for post-mastectomy breast reconstruction. Aesthetic Plast Surg. 2010;34:475480.
66. Petit JY, Lohsiriwat V, Clough KB, et al. The oncologic outcome and immediate surgical complications of lipofilling in breast cancer patients: A multicenter study. Milan-Paris-Lyon experience of 646 lipofilling procedures. Plast Reconstr Surg. 2011;128:341346.
67. Seth AK, Hirsch EM, Kim JY, Fine NA. Long-term outcomes following fat grafting in prosthetic breast reconstruction: A comparative analysis. Plast Reconstr Surg. 2012;130:984990.
68. Brenelli F, Rietjens M, De Lorenzi F, et al. Oncological safety of autologous fat grafting after breast conservative treatment: A prospective evaluation. Breast J. 2014;20:159165.
69. Kronowitz SJ, Mandujano CC, Liu J, et al. Lipofilling of the breast does not increase the risk of recurrence of breast cancer: A matched controlled study. Plast Reconstr Surg. 2016;137:385393.
70. Silva-Vergara C, Fontdevila J, Descarrega J, Burdio F, Yoon TS, Grande L. Oncological outcomes of lipofilling breast reconstruction: 195 consecutive cases and literature review. J Plast Reconstr Aesthet Surg. 2016;69:475481.
71. Rubin JP, Coon D, Zuley M, et al. Mammographic changes after fat transfer to the breast compared with changes after breast reduction: A blinded study. Plast Reconstr Surg. 2012;129:10291038.