The best candidates for breast augmentation by any modality are nonobese women displaying relatively symmetrical breasts, a symmetrical frame and lacking breast ptosis. Ptosis is evaluated with the patient standing and is defined as descent of the center of the nipple-areola complex (NAC) below the level of the inframammary fold (IMF). Grading systems are described elsewhere (6).
The best candidates for cosmetic breast augmentation by autologous fat transfer are those seeking a modest increase in size, who (1) have adequate fat deposits for harvest by liposuction, (2) understand that an unpredictable proportion of the transplanted fat and associated volume, will resorb during the healing phase, (3) are aware that multiple sessions may be required to achieve a suitable size increase, and (4) are aware that saline or silicone implants are options that deliver predictable size augmentation and they reject those options.
The correction of contour irregularities around existing saline or silicone breast implants is a less common, but effective application of autologous fat transfer to the breast. It is prudent in such cases to be fully prepared to perform an implant exchange at surgery in the event of accidental implant perforation. Rippling and upper pole volume deficiencies respond well to fat transplantation. Capsular contracture has been reported to improve after fat grafting around the constricted capsule (4).
Screening & Evaluation
The ideal cosmetic breast patient has no breast symptomatology, pathology, or risk factors for breast disease. Breast specific screening begins with a thorough history and family history followed by a complete physical examination of the breasts with attention to any masses or lymphadenopathy. A history of breast cancer treated by conservative resection is an absolute contraindication to the procedure. Mammography is performed on patients meeting either medical diagnostic or routine screening criteria. Some surgeons prefer to screen all cosmetic breast patients with mammography prior to surgery because of concern that postsurgical changes may obscure subsequent breast cancer screening. All patients are counseled that cosmetic breast surgery may produce calcifications, cysts or palpable lumps that may require diagnostic imaging and interventions including biopsy and can never be assumed to be benign.
Medications, supplements, herbs and other substances with the capacity to impair coagulation should be discontinued in advance of surgery. Substances which interact negatively with anesthetic agents and perioperative medications should also be withheld. If they cannot be discontinued or substituted, the surgical plan will need to be modified, delayed or withheld. Cigarette smoking is not a contraindication to liposuction nor to autologous fat transfer, but smokers typically display an atrophic dermis and less skin elasticity which both increase the likelihood of postoperative skin wrinkling. They also demonstrate greater resorption of transplanted fat.
Photography of the breasts prior to surgery, before and after marking their measurements, completes the preoperative process. Written release forms specific to photography are mandatory. A routine that includes frontal, oblique and lateral views with arms both at rest and elevated provides an accurate record of asymmetries and of any preexisting scars or contour deformities.
External Tissue Expanders
More recently, however, the Brava device has been utilized as a means of expanding the superficial planes of the breast in preparation for autologous fat transfer allowing for more fat to be injected under less pressure. The protocol under study involved 4 weeks of pre-operative Brava use for 10 hours daily followed by postoperative use as a shape-supporting stent for the first 7 days (8).
Adipose-Derived Stem & Stromal Cells (ADSCs)
Platelet-Rich Plasma (PRP)
Broad spectrum prophylactic antibiotics targeting skin flora are administered intravenously immediately prior to surgery and the patient is positioned in the supine position with the arms away from body. Continuous noninvasive monitoring of blood pressure, pulse oximetry and 3- or 5-lead EKG are instituted. The skin is scrubbed with chlorhexidene or betadine and latex free drapes are applied.
The procedure begins with TLA infiltration of the harvest areas and of the breasts. The harvest sites are infiltrated to a tumescent level of tightness by standard techniques described elsewhere (15). TLA is administered via infusion pump and a long spinal needle (18G x 6”, Quincke tip). TLA concentrations per liter of normal saline are as follows: lidocaine 750mg, epinephrine 1mg, sodium bicarbonate 10mEq (8.4% x 10ml). The total lidocaine dose should not be allowed to exceed 50mg/kilogram of body weight. We prefer sharp spinal needles over reusable blunt-tipped infiltration cannulas because (1) they pass through the dense breast connective tissue with far less resistance and tissue drag which results in smoother and more precise guidance by the surgeon, and (2) by the nature of their design, spinal needles deliver the anesthetic fluid wave ahead of the sharp instrument tip thereby minimizing any painful needle tip sensation by the patient.
TLA infiltration of the breast in preparation for autologous fat transfer is distinct: A low-volume infiltration of TLA is administered superficially over the entire breast mound approximately 1-cm in thickness. A deeper infiltration is not carried out because the autologous fat is injected superficially. A larger volume infiltration will distort the tissues and impede the accuracy of the augmentation.
Once the breasts and the harvest sites have been anesthetized adequately, liposuction fat harvesting is carried out using standard technique (15). Cannulas of 3-mm diameter or narrower are preferred because they deliver small fat parcels which are easy to inject through narrow fat transfer cannulas and produce a smoother fill. Fat is collected in either a syringe
The centrifuged fat is transferred to small syringes in preparation for injection. We prefer 5-10cc syringes. Blunt-tipped 14G x 15cm injection cannulas with single side ports (Coleman Type II) are attached to the syringes for the injection process.
It should be noted that current techniques of autologous fat transfer to the breast intentionally avoid direct injection into the breast parenchyma. While the injection of the superficial planes usually gives sufficient size enhancement, some surgeons seeking to achieve increased breast mound projection target additional injections into the pectoralis major and the prepectoral layers.
The patient is seen for follow-up at 24-48 hours post-surgery primarily for surveillance of the harvest sites. Active fluid expression of these areas, if necessary is conducted by the nursing team. The breasts are examined for signs of excess bruising or infection; the latter is rare. Oral broad spectrum antibiotic coverage for skin pathogens is maintained for the first seven days after surgery. Analgesic needs are typically minimal and NSAIDs are usually sufficient. Patients are able comfortably to return to a desk job by 48 hours post-surgery. Additional postoperative surveillance is conducted on a bi-weekly, then monthly basis as deemed appropriate. The final breast volume stabilizes by approximately three months after surgery.
Significant loss of augmented breast volume is common especially in cigarette smokers. The patient needs to be counseled thoroughly prior to surgery that a noticeable portion of the immediate postoperative fill volume represents anesthetic fluid within the breast and fluid within the transplanted fat. Interventions which promote the healing process include adequate caloric intake and smoking cessation, but these no offer no guarantee of superior results. Repeat sessions of autologous fat transfer to the breast should be scheduled at an interval that allows for complete healing and revascularization of the recipient site; typically three months or more.
One small case series from Japan, of patients presenting with palpable indurations six months to six years post injection by “untrained individuals” reported pain, infection, breast discharge, lymphadenopathy, and cysts requiring surgical excision (16). They and others have postulated that possible large volume mass injection is a contributing factor to large areas of fat necrosis (16-18).
Mammographic changes observed in breasts subjected to autologous fat transfer include various calcifications, cysts, and tissue remodeling in less than half of patients (17). It has been argued that these changes may interfere with breast cancer screening (16, 19), but it has also been argued that the incidence and significance of these findings are no worse than those following other cosmetic breast procedures (4, 20). Furthermore, it has been stated that radiographic multimodal follow-up evaluation is effective at discerning the characteristics of injected fat over time and that no increase in the increase of breast cancer has been reported to date (17, 21).
2. Bircoll MJ. Case report: Cosmetic breast augmentation utilizing autologous fat and liposuction techniques. Plast Reconstr Surg 1987;79:267-71.
3. ASPRS Ad-Hoc Committee on New Procedures. Report on autologous fat transplantation. September 30, 1987.
4. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: Safety and efficacy. Plast Reconstr Surg 2007; 119:775-85.
5. Gutowski KA. Current applications and safety of autologous fat grafts: A report of the ASPS Fat Graft Task Force. Plast Reconstr Surg 2009;124:272-80.
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19. Spear S, Al-Attar A. Discussion: Mammographic changes after fat transfer to the breast compared with changes after breast reduction. Plast Reconstr Surg 2012;129:1039-41.
20. Rubin JP, et al. Mammographic changes after fat transfer to the breast compared with changes after breast reduction: A blinded study. Plast Reconstr Surg 2012:1029-38.
21. Carvajal J, Patiño JH. Mammographic findings after breast augmentation with autologous fat injection. Aesthet Surg J 2008;28:153-62.