Fat transfer, or fat grafting, has been among the most significant advances in breast surgery over the past 20 years. Breast lipofilling helps correct contour, volume, and shape problems. Breast lipofilling can treat prosthesis-related defects or complications. In addition, chest lipofilling has numerous indications in breast surgery.
Contrary to prosthesis implantation, breast lipofilling is used for patients who require only moderate breast augmentation or for those who wish to recover their former breast size, for instance, after weight loss or pregnancy.
The Coleman technique should be considered the standard and preferred method for harvesting, processing, and placement. Coleman’s technique emphasizes gentle fat extraction, fat washing and centrifugation, and precise placement of tiny fat parcels.
Breast Lipofilling Donor Site
A variety of body areas that uniformly have much or excess fat are suitable as donor sites, such as the abdomen, flanks, buttocks, medial and lateral thighs, or knees. Donor site selection is determined by patient preference, the amount of fat required, and the amount of fat available at different sites.
Breast Lipofilling Patient Positioning
Donor and recipient sites dictate patient positioning.
Breast Lipofilling Incision Sites
The harvest site is prepared with betadine. The stab incision sites are anesthetized with 1% lidocaine with epinephrine. Using A No. 11 blade scalpel creates 2- 3-mm incisions for local anesthesia infiltration and fat extraction. Incisions are usually chosen to be hidden in natural skin folds, scars, stretch marks, or hair-bearing areas.
Breast Lipofilling Local Anesthesia
Local anesthesia serves several purposes. It facilitates fat extraction and decreases pain and ecchymosis postoperatively. Depending on patient preference and the volume of fat required, fat can be harvested with local anesthesia only with or without IV sedation.
Local anesthetic solution is infiltrated through these incisions using a 2mm multi holes blunt infiltration cannula attached to a 20ml syringe in a fanning technique. The total volume of local anesthesia should equal the fat required at most.
Breast Lipofilling Fat Harvesting (extraction)
A multi holes 2-3mm harvesting cannula attached to a 10-mL syringe is then used to suction the fat. The syringe plunger is pulled back only a few milliliters to create enough vacuum to harvest the fat while avoiding excessive pressure.
Fat is extracted by forwarding and backward movements with a simultaneous backward movement of the syringe plunger. As fat is harvested, the first few syringes occasionally have more local anesthetic than later. As suction continues, later syringes contain less infiltration and more blood. We prefer painting incision sites with the supranate oily fatty layer.
Breast Lipofilling Fat Processing and Purification
Fat processing is necessary as lipoaspirate contains adipocytes, collagen fibers, blood, and debris. These elements can cause inflammation at the breast site, which can be detrimental to the fat graft. Blood must be extracted because blood accelerates the degradation of the transplanted fat. Moreover, the injection of debris gives an erroneous impression of the volume of correction because the debris will be absorbed after a few hours.
The survival of free grafts (skin, bone, cartilage, cornea, and so forth) requires maintenance of tissue architecture, not just the transplantation of cells. Therefore, maintaining the tissue architecture of living fat is crucial. Fat is fragile tissue that may not survive the trauma of harvesting, refinement, transfer, and insertion into a donor site. Each step can potentially injure the fat cell or destroy the fatty tissue architecture.
The most used methods to prepare fat grafts are sedimentation, filtering, washing, and centrifugation. The author prefers using sedimentation, washing if needed, and centrifugation. Sedimentation for 15 minutes lipoaspirate separates into two layers. The lower fluid portion is decanted before centrifuging, and the only upper fatty portion is transferred to the centrifuge.
Unprocessed fat was loaded into the centrifuge and spun for 1 to 3 minutes atm 3000 RPM. After being centrifuged, lipoaspirates with the syringe are divided into three layers: the oil content in the upper layer, fatty tissue in the middle layer, and the fluid portion at the bottom.
The oil can be decanted from the Luer-Lok syringe. The residual oil is wicked with a cotton strip or swab, and the fluid at the bottom can be quickly drained out.
Fat is transferred into the back end of a 10-mL syringe to facilitate transfer into the 3-mL infiltration syringes. The middle fatty layer is transferred to the syringe with the 3-mL syringe via a Luer-Lock connection.
Breast Lipofilling Fat Placement
Placement of the refined fat into the breast is the most challenging part of fat grafting. The infiltration cannula is inserted through each tiny incision used for infiltration of the local anesthetic and advanced through the breast tissues to the appropriate plane.
However, additional incisions might be needed for even fat grafting distribution on the breast with an 18-gauge Nokor needle. Once the cannula is in the desired plane, the plunger of the 3 mm syringe is pressed slightly while the cannula is withdrawn. The deposited fatty tissue parcels fall into the natural breast tissue planes as the skin covering the breast collapse around them.
Placing the fatty parcels with a blunt cannula that causes minimal disruption of the natural tissue planes facilitates better fat adherence to the recipient sites.
Minimal destruction of the tissue planes and maximal surface area of contact combine to create a more stable relationship between the new fat parcels and the surrounding tissues.
The key to the placement of fatty tissue is the maximization of the surface area of contact between the harvested fat and the recipient tissues. The larger surface area of contact can be maintained by placing these small parcels of fat so that they are separated from each other by the host tissue.
Grafting with a small volume in each pass will not only produce a better surgical outcome but also can help avoid complications such as fibrosis, oil cyst formation, calcification, and even infection associated with large-bolus grafting. On the other hand, injection of a fat mass into any site may result in areas of fat that are too far from vascularized tissue to have a source of nutrition or respiration. In this event, much of the tissue will die or resorb, resulting in irregularities. Fat placement or injection is done from a deep to a superficial plane, realizing a 3-dimensional pattern.
To summarize successful fat graft placement, the following points should be stressed:
- Fat grafts should be injected in each pass with a small volume (no more than 0.1 ccs)
- Small aliquots of fat should be placed within multiple tissue planes and tunnels in multiple directions.
- A slow injection of 0.5 to 1 cc per second should be done
- The injection is done during the withdrawal phase to minimize trauma to the fat graft.
Breast Lipofilling Post Operative Care
I believe that icing immediately postoperatively is necessary to decrease the metabolic requirement of fat graft. Furthermore, it decreases postoperative bruises and swelling. We advocate icing intermittently for at least the first 48 to 72 hours postoperatively.
During the recovery time, ice packing, tight compression with an elastic bandage, or massage in the grafted area should be avoided because all the above may compromise fat graft survival and the outcome. Any direct trauma or shear force over the grafted areas may jeopardize fat graft survival and should be avoided.
The post-grafting care should immobilize the graft and prevent the natural recoil from shrinking. Therefore, immobilize the graft for a few days by lightly applying an elastic conforming bandage over the breast. Taping over the grafted areas may relieve discomfort from swelling, prevent patients from pressing or touching the areas, and protect direct trauma or shear force over the grafter areas.
Alternatively, one can use external volume expansion at 20 mmHg to preserve the expansion and immobilize the fat grafting.
How Does fat Graft Survive?
The fat cells survive by oxygen diffusion in the breast site during the initial days after grafting, eventually forming a viable blood supply. Overcrowding fat cells interferes with oxygen diffusion, leading to cellular death and graft volume loss.
On the other hand, most transplanted fat cells die and act as a nonviable scaffold, through which blood stem cells penetrate and initiate a process of living new fat cells and new blood vessels. The author believes in both possibilities. In small-volume fat grafting, diffusion may play a more significant role; in large-volume grafting, more cells may not survive, and the scaffold effect may play a relatively more significant role.
Breast Lipofilling Complications
Donor-site complications appear minimal and are related to the liposuction technique (bruising, swelling, and contour irregularities.
Fat breast injection can cause fat necrosis, oil cyst formation, and calcification. These changes fail “graft take” and lead to palpable masses due to fat necrosis. Infection after fat grafting is exceedingly rare. The most feared possible complication of fat grafting is fat embolism from an intravascular infusion. This complication is infrequent and has never been reported with the use of blunt tip cannulas for placement
The technique of breast fat injection allows Prof. Moawad has excellent control in sculpting the breasts to the required contour, especially in the correction of tuberous breast deformity. In this case, no fat graft is emplaced beneath the nipple-areola complex (NAC).
Breastg Lipofilling In Breast Surgery
The shape of the breasts depends on the rib cage, the pectoralis muscle, the breast parenchyma, fatty tissue, and the overlying skin quality. Indications of lipofilling breast can be divided into esthetic and reconstructive, although some cases show overlap.
- Primary breast augmentation
- Breast implants to disguise animation deformities and improve capsular contractures.
- To take the place of implants in removal implant surgery.
- Tom to correct tuberous breasts and Poland syndrome.
- Provide coverage over a bony sternum or fill pectus excavatum.
- To precisely fill a lumpectomy or biopsy defect.
- To reverse radiation skin damage after breast cancer treatment.
- To reconstruct a breast after mastectomy.
I will start first with esthetic breast augmentation.
Breast Lipofilling in Aesthetic Breast Surgery
There are certain preconditions to be followed during the breast enlargement process using only lipofilling or fat augmentation.
- A BMI of 18 or less indicates postponing lipofilling of the breast until the patient gain 2-3 kilos.
- About half a cup volume (silicone implant of 100-150 ml) can be gained per lipofilling session.
- Therefore, the patient must be informed that she needs at least two fat grafting sessions to gain a total cup size. These can be carried out after a gap of 3 months.
Breast Lipofilling in Combined Breast Augmentation (CBA)
There is the possibility to improve the outer silhouette of the silicone implant through additional autologous fat, either done simultaneously or secondarily. In these cases, 100-200 ml fat can achieve a good contour shaping and natural feel.
Breast Lipofilling Around the Implant Capsule
Lipofilling improves scar tissue and capsular fibrosis that present as rippling. The fat tissue is introduced through several points from the areola boundary laterally around the capsule. The quantity of tissue utilized here lies at about 100 mL per breast. When the job is carried out carefully, there is only a slight danger of an injury to the implant.
Breast Lipofilling in Implant Removal
Once capsular fibrosis is detected, there is a high chance of a relapse. Therefore, in small implants (upto250 ml), the implant is removed entirely and replaced with fat. In larger implants (more than 350ml), the patient should decide upon combined breast augmentation or fat alone with suboptimal aesthetic results.
The removal of the implant is done most conveniently through the sub-mammary fold. It is essential to leave the capsule entirely in situ due to an ideal blood supply on its surface. The subcutaneous injection is given in the same manner as described in the case of aesthetic augmentation. The cannula is inserted through the inframammary wound. A perforation in the capsule should be carefully avoided, but if it still happens, the fat that may enter the empty capsule should be drained at the end of the operation.
When dealing with a defective implant, a cleaning process must be carried out so that no more silicone residue can be observed. The lower boundary of the capsule is exposed and opened, and the implant is extracted from here. Then a basic cleaning of the capsule is carried out by repeated flushing and wiping until an optical impression of a clean inner capsule surface is obtained. Exclusively the subcutaneous tissue and the skin are closed.
Breast Lipofilling in the Treatment of Tuberous (Tubular) Breasts
Tuberous breast deformity is a small asymmetric breast with a lax, prolapsed nipple area. It appears at puberty with the growth of the breast. Lipofilling is similar to aesthetic breast enlargement in two to three steps.
A sub-mammary fold is filled in the first stage, injecting the fat below the old sub-mammary fold at 8–10 cm lower than the nipple. In the second step, the nipple area is corrected after three months. For this purpose, the areola is marked reduced to the desired size.
Lipofilling is done in the same distribution analogous to primary breast enlargement subcutaneously and a retro-glandular area. Lipofilling is generally superior in the correction of tuberous breast deformity as compared to silicone implants.
Treatment with the BRAVA System offers a good alternative. When external negative pressure is placed on the breast, BRAVA pre-expansion may accentuate breast contour irregularities due to infra-mammary fold constrictions, tuberous breast constrictions, or internal scars in the breast.
Breast Lipofilling in Breast Asymmetries
Compensation for breast asymmetry is complex to manage. It is an individual decision whether an operative reduction on the other side should be performed. The standard treatment is the placement of a prosthesis to enlarge the small breast. Results are generally satisfactory, though asymmetry (both in form and volume) generally reappears after several years.
Lipomodeling can be used to re-sculpt the small breast and restore a shape and volume like that of the normal breast. The treatment allows for very natural evolution over time and normal ptosis. Therefore, lipofilling of the breast is an ideal solution for the compensatory correction of size and contour and is vastly superior to silicone implants.
One to three grafting sessions (usually two) are required, depending on the extent of the asymmetry and the degree of hypotrophy. Since half a breast size can be compensated per sitting, the number of necessary sittings and volume should be precisely planned. If both breasts must be increased in size, one must start with the smaller size
Even thoracic deformities and general asymmetries like outwardly pointing nipples can be appropriately corrected. A sub-mammary fold located at a higher level, which is frequently the case on one side, can be lowered by direct injection.
Breast Lipofilling in Treating Chest Anomalies (Pectus Excavatum)
Pectus excavatum is a complex deformity in which the depression of the sternum and adjacent ribs results in a hollow chest wall. If pectus excavatum is restricted to one side of the chest, it may affect the shape of the patient’s breast.
Due to the high rate of complications of an invasive operation, the shallow rate of complications and low postoperative morbidity of an operational correction using lipofilling appear to be of great interest. Generally, between two and three transplants, an average of 100 mL of fat appears to be sufficient.
Lipofilling can provide satisfactory results in this indication, either in patients with moderate or mild deformity or in combination with patient-tailored silicone prosthesis for more severe forms.
Breast Lipofilling in Treating Poland Syndrome
The Poland syndrome is a complex congenital malformation. It consists of thoracic deformity, hypoplasia of the muscle M. pectoralis major, and hand malformation. Mammary asymmetry is seen as hypoplasia of the breast and the nipple-areola complex. Correcting deformations of the breast and thorax associated with Poland’s syndrome remains a daunting challenge for plastic surgeons.
The correction of the less complicated Poland syndrome is like the therapy of the pectus excavatum. Conventional procedures include the insertion of the M. latissimus dorsi, and silicone implants will leave extra scars on the breast and the back, significant lifting defects, and asymmetry.
Breast lipofilling will depend on the volume of the normal breast, the possibility of harvesting fat, and the patient’s desire. The reconstruction is either exclusively carried out through lipofilling or by the additional use of an implant.
The breast lipofilling required an average of three sessions per patient and 244 ml of transplanted fat per session. The significant advantage as against other procedures lies in the skin cover expansion with a gradual shift of the areola. A buildup is possible only through three to six fat grafts if a large volume is missing.
Breast Lipofilling and Breast Lifting Surgery
Any breast lift can be combined with Breast lipofilling. Fat to be grafted is introduced only into the area away from the surgical wound. Fat is an injection in the upper quadrants of the breast, about 100-150 ml per site. Fat injection can be injected even sub- muscular for a better breast projection.
Constructed Breast Lipofilling with Latissimus Dorsi
Breast Lipofilling of a reconstructed breast has many advantages: autologous reconstruction process, cost-effectiveness, reproducibility, natural consistency and appearance of the breast, breast symmetry, and finally, treatment of fat deposits in the donor regions.
Autologous breast reconstruction does not have implant-related complications and produces a more natural breast. Extensive fat grafting could be transferred in 1 session (up to 500 mL per breast) with excellent results. Breast Lipofilling starts from the bone plane to the pectoralis major and then to the breast, ending in the subcutaneous plane
Reconstructed Breast Lipofilling with TRAM or DIEP
During the second stage of surgery, breast lipofilling is done mainly on the locations that lack volume. Another advantage of fat grafting is the correcting abdominal and flanks contour. It is mandatory to transfer less fat in a TRAM or a DIEP than one could do in a latissimus dorsi flap because the former is less vascularized.
Reconstructed Breast Lipofilling with Implant
Implant reconstructed breast deformities are of 3 types:
- Decollate’ asymmetry with step appearance of the prosthetic breast,
- Medial deformity with step and too wide intermammary,
- Lateral deformity with lack of volume above the anterior axillary line.
In the décolleté’, lipofilling is done in the pectoralis major muscle. In the medial and lateral deformities, lipofilling is in the pectoralis major and between the skin and capsule at the implant change.
Breast Lipofilling after Conservative Surgery
Breast lipofilling is a massive step in the therapeutic possibilities of surgical management of conservative surgery moderate sequelae. Breast imaging is not affected by the technique, and fat grafting does not prevent an accurate radiologic breast screening.
The technique is done with strict radiologic screening in conservative breast surgery patients. If a suspicious lesion is visualized, a micro biopsy is done. The risk of coincidence with new cancer, or a recurrence of the previous one, is high.
Reconstruction of Breast by Lipofilling Only
Breast lipofilling alone best suits small or medium-sized breasts and patients presenting sufficient fat deposits. In a non-irradiated breast after mastectomy, 3 to 4 sessions are needed to achieve breast reconstruction with contralateral symmetry. In the presence of radiotherapy, 4 to 6 sessions are needed to obtain optimal results.
Reconstructed Breast Lipofilling after Radiotherapy
Breast Lipofilling can be done on very thin or irradiated skin 2 to 3 months before planned reconstruction to prepare the thoracic area. In this indication, 80 to 200 mL of fat is transferred. Skin quality is enhanced, and necrosis is prevented.
SUMMARY of Breast Lipofilling
The plastic surgery community’s acceptance of breast lipofilling has created many possibilities for cosmetic and reconstructive surgeons. Small and large breast defects can be filled; bony prominences and visible implant edges can be disguised; radiation skin damage can be improved; reconstructions can be refined; difficult breasts can be precisely shaped; implants can be removed and replaced with fat; and a simple, natural augmentation can be performed. Breast lipofilling is a time-consuming, meticulous procedure that, although exciting in its range of possibilities, should be done with great care.