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TitleAutologous Fat Transfer: Art, Science, and Clinical Practice
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Table of Contents
                            3642004725
Autologous Fat Transfer
Art, Science, and Clinical Practice
Foreword
Preface
Contents
Contributors
Part I History, Principles, Fat Cell Physiology and Metabolism
	History of Autologous Fat Transfer1
		1.1 Introduction
		1.2 History
		References
	History of Autologous Fat Transplant Survival1
		2.1 Introduction
		2.2 Historical Review
		References
	Principles of Autologous Fat Transplantation
		3.1 Introduction
		3.2 Fat Transplant Survival
		3.3 Indications for Fat Transplantation
		3.4 Complications of Fat Transplantation
		3.5 Technique of Autologous Fat Transplantation
		3.6 Insulin
		3.7 Centrifugation
		3.8 Ratchet Gun for Injection
		3.9 Severing Tethering Bands
		3.10 Machine Liposuction
		3.11 Specific Principles
		References
	The Adipocyte Anatomy, Physiology, and Metabolism/Nutrition
		4.1 Introduction
		4.2 Histology
		4.3 The Interstitium
		4.4 Physiology
		4.5 Gross Anatomy
			4.5.1 Apical Layer
			4.5.2 Mantle Layer
			4.5.3 Deep Layer
		4.6 Deep Fat of the Neck
		4.7 Upper Arm Fat
		4.8 Abdomen
		4.9 Hips and Flanks
		4.10 Thighs and Buttocks
		4.11 Lower Leg
		4.12 Nutrition and Metabolism
		4.13 Fat’s Future
		4.14 Conclusions
		References
	Fat Cell Biochemistry and Physiology
		5.1 Introduction
		5.2 Fat Cells
		5.3 Lipolysis
		5.4 Multilineage Cells in Fat
		5.5 Obesity
		5.6 Diabetes
		5.7 Hypertension
		5.8 Hematopoiesis
		5.9 Inflammatory Response
		5.10 Traumatic Lipomas
		5.11 Multiple Symmetrical Lipomatosis
		5.12 Discussion
		References
	White Adipose Tissue as an Endocrine Organ
		6.1 Introduction
		6.2 Role of White Adipose Tissue in Metabolism
		6.3 Leptin on Brain
		6.4 Adiponectin on Liver and Muscle
		6.5 Location of WAT
		6.6 Adipokines and Inflammation
		6.7 Conclusions
		References
Part II Preoperative
	Preoperative Consultation
		7.1 Introduction
		7.2 Initial Conference
		7.3 Physical Examination
		7.4 Discussion with the Patient
		7.5 Laboratory Studies
		7.6 Radiologic Studies
		7.7 Written Instructions
		7.8 Postoperative
		7.9 Conclusions
Part III Techniques for Aesthetic Procedures
	Guidelines for Autologous Fat Transfer, Evaluation, and Interpretation of Results
		8.1 Introduction
		8.2 Conclusions
		References
	Face Rejuvenation with Rice Grain-Size Fat Implants1
		9.1 Introduction
		9.2 History
		9.3 Preoperative Evaluation
		9.4 Harvesting
		9.5 Fat Processing
		9.6 Fat Transfer
		9.7 Postoperative Care
		9.8 Discussion
	Fat Transfer in the Asian
		10.1 Introduction
		10.2 Cultural Issues
		10.3 Strategies for the Aging Asian Eyelid
		10.4 Aging Asian Eyelids with a Natural Supratarsal Crease
		10.5 Aging Asian Eyelids Without a Supratarsal Crease
		10.6 Aging Asian Eyelids with a ­Man-Made Crease
		10.7 Strategies for the Aging Asian Face
		10.8 Conclusions
		References
	Subcison with Fat Transfer
		11.1 Introduction
		11.2 Subcision
		11.3 Autologous Fat Injection
		11.4 Conclusions
		References
	Autologous Fat Transplantation for Acne Scars
		12.1 Introduction
		12.2 Volumizers and Fillers
		12.3 Treating Scar Tissue
		12.4 Physiology of Acne Scars
		12.5 Evaluating Acne Scars
		12.6 Acne Scar Morphology
		12.7 Acne Scar Treatment Options
		12.8 Lipofilling Acne Scars (Figs. 12.1–12.4)
		12.9 Longevity
		12.10 Complications
		12.11 Conclusions
		References
	The Art of Facial Lipoaugmentation
		13.1 Introduction
		13.2 Goals of Lipoaugmentation
		13.3 Instrumentation
		13.4 Technique
			13.4.1 Donor Site
			13.4.2 Recipient Site
			13.4.3 Final Fat Preparation
			13.4.4 The Malar Fat Pad
			13.4.5 Other Facial Enhancements
		13.5 Repeat Procedures
		13.6 Conclusions
		References
	Use of Platelet-Rich Plasma to Enhance Effectiveness of Autologous Fat Grafting1
		14.1 Introduction
		14.2 General Biology of Wound and Graft Healing with PRP
		14.3 Autologous Fat Graft Healing Model
		14.4 PRP Technique
			14.4.1 Isolation of Platelet-Rich Plasma
		14.5 Harvest of Autologous Fat by Closed Syringe
		14.6 Autologous Fat Grafting with PRP
		14.7 Results and Complications Using PRP
		Discussion
		Conclusions
		References
	Fat Transfer to the Face
		15.1 Introduction
		15.2 History of Fat Transfer
		15.3 Insulin
		15.4 Centrifugation
		15.5 Ratchet Gun for Injection
		15.6 Albumin in Improving Fat Cell Survival
			15.6.1 Oncotic Pressure
			15.6.2 Colloid Osmotic Pressure
		15.7 Starling’s Equation
		15.8 Avoiding Hypo-Oncotic Trauma in Fat Transfer
		15.9 Indications for Fat Transfer
		15.10 Preoperative Consultation
		15.11 Technique
		15.12 Complications
		15.13 Conclusions
		References
	Fat Autograft Retention with Albumin
		16.1 Introduction
		16.2 Background
		16.3 History
		16.4 Microenvironment
		16.5 Starling’s Equation
		16.6 Effect of Tumescence
		16.7 Use of Albumin to Correct pi Deficit Physical Characteristics
		16.8 Importance of Not Washing
			16.8.1 The Interstitium
		16.9 Procedure and Methods
		16.10 Case Results
		16.11 Fat’s Future
		16.12 Conclusions
		References
	Aesthetic Face-lift Using Fat Transfer
		17.1 Introduction
		17.2 Anatomy and Pathophysiology
		17.3 Advantages and Disadvantages
		17.4 Patient Selection
		17.5 Potential Areas for Facial Fat Transfer
		17.6 Technique
		17.7 Fat Harvesting
		17.8 Fat Injection Technique
		17.9 Postoperative
		17.10 Graft Survival
		17.11 Other Indications
		17.12 Discussion
		17.13 Conclusions
		References
	Fat Transfer to the Glabella and Forehead1
		18.1 Introduction
		18.2 Glabella and Forehead
		18.3 Equipment
		18.4 Anesthetic
		18.5 Injection Technique
		18.6 Results
		18.7 Expectations of Fat Survival
		18.8 Complications
		18.9 Discussion
		References
	Eyebrow Lift with Fat Transfer
		19.1 Introduction
		19.2 Technique
		19.3 Postoperative Care
		19.4 Discussion
	Treatment of Sunken Eyelid
		20.1 Introduction
		20.2 Refilling
			20.2.1 Fat Graft
		20.3 Dermofat Graft (Fig. 20.6)
		20.4 Others
		20.5 Repositioning
		20.6 Conclusions
		References
	Fat Graft Postvertical Myectomy for Crow’s Feet Wrinkle Treatment
		21.1 Introduction
		21.2 Technique
		21.3 Conclusions
		References
	Optimizing Midfacial Rejuvenation: The Midface Lift and Autologous Fat Transfer
		22.1 Introduction
		22.2 Methods
		22.3 Surgical Technique
			22.3.1 Fat Retrieval
		22.4 Fat Processing
		22.5 Fat Transfer Procedure
		22.6 Complications
		22.7 Results
		22.8 Discussion
		References
	Autologous Fat Transfer to the Cheeks and Chin
		23.1 Introduction
		23.2 Anatomy
		23.3 Technique
		23.4 Complications
			23.4.1 Bruising
			23.4.2 Infection
			23.4.3 Asymmetry
			23.4.4 Loss of Volume
			23.4.5 Neuralgia
			23.4.6 Fat Cysts or Fibrosis
		23.5 Discussion
		23.6 Conclusions
		References
	Nasal Augmentation with Autologous Fat Transfer
		24.1 Introduction
		24.2 Surgical Technique
		24.3 Postoperative Problems
		24.4 Conclusions
		References
	Lipotransfer to the Nasolabial Folds and Marionette Lines
		25.1 Introduction
		25.2 Technique
			25.2.1 Preparation of Donor Site
			25.2.2 Preparation of Recipient Site
		25.3 Harvest
		25.4 Processing of Fat
		25.5 Injection of Fat
		25.6 Complications
		25.7 Discussion
		25.8 Conclusions
		References
	Autologous Fat Transplantation to the Lips
		26.1 Introduction
		26.2 Preoperative Evaluation
		26.3 Technique
		26.4 Harvesting of Fat
		26.5 Injection Technique
		26.6 Fat Storage
		26.7 Complications
		26.8 Discussion
		References
	Three Dimensional Facelift
		27.1 Introduction
		27.2 Rejuvenation
		27.3 Muscle Laxity
		27.4 Volume Depletion
		27.5 Patient Consultation
		27.6 Procedure
		27.7 Postoperative Care
			27.7.1 First Postoperative Day
			27.7.2 Second Postoperative Day
			27.7.3 Third Postoperative Day
			27.7.4 Fourth Postoperative Day
			27.7.5 Fifth and Sixth Postoperative Days
			27.7.6 Seventh Postoperative Day
			27.7.7 Tenth Postoperative Day
		27.8 Discussion
		27.9 Complications
		27.10 Conclusions
	Complementary Fat Grafting of the Face
		28.1 Introduction
		28.2 Technique
		28.3 Marking the Recipient Sites
		28.4 Selecting Donor Site
		28.5 Donor-Site Harvesting
		28.6 Processing the Fat
		28.7 Injection Techniques
			28.7.1 General Principles
			28.7.2 Systematic Site-Specific Infiltration
				28.7.2.1 Inferior Orbital Rim (from Port A)
				28.7.2.2 Nasojugal Groove (from Port A)
				28.7.2.3 Lateral Canthus (from Port B)
				28.7.2.4 Lateral Brow (from Port B)
				28.7.2.5 Anterior Cheek/Malar Septum (from Port B)
				28.7.2.6 Lateral Cheek (from Port A)
				28.7.2.7 Buccal Recess (from Port A)
				28.7.2.8 Prejowl Sulcus (from Port C)
		28.8 Immediate Postoperative Care
		28.9 Complications
			28.9.1 Lumps
			28.9.2 Bulges
			28.9.3 Overcorrection
			28.9.4 Undercorrection
		28.10 Discussion
		28.11 Conclusions
	Fat Transplants in Male and Female Genitals1
		29.1 Introduction
		29.2 Preoperative Preparation
		29.3 Technique
		29.4 Penile Enhancement
		29.5 Vulvar Enhancement
		29.6 Postoperative Care
		29.7 Complications
		29.8 Discussion
		29.9 Conclusions
		References
	History of Breast Augmentation with Autologous Fat
		30.1 Introduction
		30.2 Historical Contributions
		30.3 Recent History with Liposuctioned Fat
		30.4 Discussion
		References
	Breast Augmentation with Autologous Fat
		31.1 Introduction
		31.2 Technique
		31.3 Case Reports
		31.4 Discussion
		References
	Fat Transfer and Implant Breast Augmentation
		32.1 Introduction
		32.2 Technique
		32.3 Clinical Case
		32.4 Discussion
		References
	Fat Transfer with Platelet-Rich Plasma for Breast Augmentation1
		33.1 Introduction
		33.2 General Biology of Wound and Graft Healing with PRP
		33.3 Autologous Fat Graft Healing Model
		33.4 Technique
			33.4.1 Isolation of Platelet-Rich Plasma
			33.4.2 Harvest of Autologous Fat by Closed Syringe
			33.4.3 Autologous Fat Graft Breast Augmentation with PRP
		33.5 Results and Complications
		33.6 Discussion
		33.7 Conclusions
		References
	Cell-Assisted Lipotransfer for Breast Augmentation: Grafting of Progenitor-Enriched Fat Tissue
		34.1 Introduction
		34.2 Adipose Tissue-Specific Progenitors with Multipotency
		34.3 Biological and Therapeutic Concepts of Cell-Assisted Lipotransfer
		34.4 Concept of Cell-Assisted Lipotransfer
		34.5 Possible Roles of Adipose-Derived Stem/Stromal Cells in Cell-Assisted Lipotransfer
		34.6 Technique
		34.7 Cell Processing (Stromal Vascular Fraction Isolation Procedure)
		34.8 Results of Clinical Trials (2003–2009)
		34.9 Preoperative and Postoperative Evaluations
		34.10 Outcomes
		34.11 Discussion
			34.11.1 Refinement of Autologous Fat Graft Techniques
		34.12 Indications
		34.13 Complications
		34.14 Conclusions
		References
	Fat Transfer to the Hand for Rejuvenation
		35.1 Introduction
		35.2 Hand Rejuvenation
			35.2.1 Hand Lift
			35.2.2 Dermabrasion
			35.2.3 Skin Peel
			35.2.4 Vein Stripping
			35.2.5 Autologous Fat
			35.2.6 Silicone
		35.3 Technique for Fat Transfer
			35.3.1 Harvesting Zone Markings
			35.3.2 Operative Zone Disinfection
			35.3.3 Operative Zone Anesthesia
			35.3.4 Anesthesia of the Harvesting Zone
		35.4 Pure Hand Lipofilling Technique
		35.5 “Prepared” Fat Grafting: Delayed Harvesting
		35.6 Implant Conservation
		35.7 Complications
		35.8 Durability of Results
		35.9 Conclusions
		References
	Correction of Deep Gluteal and Trochanteric Depressions Using a Combination of Liposculpturing with Lipo-Augmentation
		36.1 Introduction
		36.2 Surgical Concepts
		36.3 Technique
		36.4 Results
		36.5 Discussion
		36.6 Conclusions
		References
	Buttocks and Legs Fat Transfer: Beautification, Enlargement, and Correction of Deformities
		37.1 History
		37.2 Technique
		37.3 Materials
		37.4 Fat as a Tissue Filler
		37.5 Placement of the Fat Graft
		37.6 Synopsis of Technique
		37.7 Qualities of Fat Transplant
		37.8 Complications
		37.9 Discussion
	Autologous Fat Transfer for Gluteal Augmentation
		38.1 Introduction
		38.2 Indications
		38.3 Technique
		38.4 Liposuction
		38.5 Fat Injection
		38.6 Further Liposuction and Injection
		38.7 Postoperative Care
		38.8 Complications
		38.9 Results
		References
	Autologous Fat for Liposuction Defects
		39.1 Introduction
		39.2 Defects Occurring During Liposuction
		39.3 Defects Following Liposuction
		39.4 Conclusions
	Periorbital Fat Transfer with Platelet Growth Factor
		40.1 Introduction
		40.2 Technique
		40.3 Periorbital Fat Graft
		40.4 Technique
	Cryopreserved Fat
		41.1 Introduction
		41.2 Review of the Literature
		41.3 Conclusions
		References
Part IV Techniques for Non-Aesthetic Procedures
	Fat Transfer for Non-Aesthetic Procedures
		42.1 Introduction
		42.2 Nonaesthetic Procedures Using Fat Transfer
			42.2.1 Breast Reconstruction
			42.2.2 Clival Cordomas
			42.2.3 Congenital Short Palate
			42.2.4 Eye Socket Reconstruction
			42.2.5 Frontal Sinus Fracture
			42.2.6 Growth Plate, Partial Closure
			42.2.7 Hemifacial Atrophy(Parry-Romberg Syndrome, Romberg Syndrome,Progressive FacialHemiatrophy, Progressive Hemifacial At
			42.2.8 Intrinsic Web Space Paralysis
			42.2.9 Lumbar Disk Herniation
			42.2.10 Lupus Erythematosis
			42.2.11 Malar Fracture
			42.2.12 Migraine Headaches
			42.2.13 Morphea Zoniform
			42.2.14 Myringoplasty
			42.2.15 Orbicularis Oculi Resection for Crow’s Feet
			42.2.16 Ozena Treatment
			42.2.17 Pectus Excavatum
			42.2.18 Postradiation Defect
			42.2.19 Sulcus Vocalis
			42.2.20 Temporomandibular Joint
			42.2.21 Thin Toes
			42.2.22 Transsphenoidal Surgery
			42.2.23 Vocal Cord Paralysis
			42.2.24 Vocal Fold Scar
		42.3 Use of Autologous Adipose Stem Cells for Nonaesthetic Transfer
		42.4 Conclusions
		References
	Fat Transplantation for Mild Pectus Excavatum
		43.1 Introduction
		43.2 Surgical Technique
		43.3 Patient Selection
		43.4 Sample Cases
		43.5 Discussion
		43.6 Conclusions
		References
	Correction of Hemifacial Atrophy with Fat Transfer
		44.1 Introduction
		44.2 Technique
			44.2.1 Timing of Operation
			44.2.2 Preoperative Preparation
			44.2.3 Fat Graft Harvesting
			44.2.4 Fat Graft Injection
			44.2.5 Postoperative Care and Follow-Up
		44.3 Complications
		44.4 Discussion
		44.5 Conclusions
		References
	Recontouring Postradiation Thigh Defect with Autologous Fat Grafting
		45.1 Introduction
		45.2 Case Report
		45.3 Technique
			45.3.1 Harvest
			45.3.2 Injection
		45.4 Discussion
		References
	Management of Migraine Headaches with Botulinum Toxin and Fat Transfer
		46.1 Introduction
		46.2 Glabellar Region
			46.2.1 History
			46.2.2 Anatomy
			46.2.3 Botulinum Toxin
			46.2.4 Role of Fat Graft
		46.3 Techniques
			46.3.1 Surgical Technique: Fat Graft Harvest in Endoscopic Approach
			46.3.2 Surgical Technique: Fat Graft Harvest in Transpalpebral Approach
		46.4 Complications
		46.5 Occipital Area
			46.5.1 Anatomy
			46.5.2 Role of Fat Transposition Flap
			46.5.3 Surgical Technique
		46.6 Conclusions
		References
	Retropharyngeal Fat Transfer for Congenital Short Palate
		47.1 Introduction
		47.2 Symptoms of Velopharyngeal Insufficiency
		47.3 Preoperative Assessment
		47.4 Criteria and Indications for Retropharyngeal Fat Injection
		47.5 Surgical Procedure
		47.6 Results
		47.7 Conclusions
		References
	Autologous Fat Grafts Placed Around Temporomandibular Joint (TMJ) Total Joint Prostheses to Prevent Heterotopic Bone
		48.1 Introduction
		48.2 Surgical Technique
		48.3 Complications
		48.4 Prevention of Fibrosis and Heterotopic Bone
		References
	Autologous Fat Grafts for Skull Base Repair After Craniotomies1
		49.1 Introduction
		49.2 Characteristics of Fat Tissue
		49.3 Technique
		49.4 Advantages, Disadvantages, and Complications
		49.5 Conclusions
		References
Part V Fat Processing and Survival
	Fat Processing Techniques in Autologous Fat Transfer
		50.1 Introduction
		50.2 Fat Processing Techniques
		50.3 Future Issues for Fat Processing
		References
	Injection Gun Used as a Precision Device for Fat Transfer
		51.1 Introduction
		51.2 Technique
		51.3 Precision Injection with Gun Injection Device
		51.4 Conclusions
		References
	Tissue Processing Considerations for Autologous Fat Grafting
		52.1 Introduction
		References
	Fat Grafting Review and Fate of the Subperiostal Fat Graft
		53.1 Introduction
		53.2 Materials and Methods
		53.3 Results
		53.4 Histopathologic Examination Findings
		53.5 Discussion
		References
Part VI Complications
	Complications of Fat Transfer
		54.1 Introduction
		54.2 Complications
			54.2.1 Viral Infection/Warty Over-Growth
		54.3 Conclusions
		References
	Facial Fat Hypertrophy in Patients Who Receive Autologous Fat Tissue Transfer
		55.1 Introduction
		55.2 Patients and Methods
		55.3 Results
		55.4 Discussion
		55.5 Conclusions
		References
	Lid Deformity Secondary to Fat Transfer
		56.1 Introduction
		56.2 Contour Deformity
		56.3 Fat Embolization
		56.4 Miscellaneous
		56.5 Conclusions
		References
Part VII Miscellaneous
	The Viability of Human Adipocytes After Liposuction Harvest
		57.1 Introduction
		57.2 Historical Perspective
		57.3 Liposuction and Free Adipose Transfer
		57.4 Viability of Human Adipocytes After Aspiration Harvest
		57.5 Aspiration Techniques
		57.6 Effect of Local Anesthesia and Epinephrine
		57.7 Tissue Handling
		57.8 Tissue Storage
		57.9 Conclusions
		References
	Autologous Fat Grafting: A Study of Residual Intracellular Adipocyte Lidocaine1
		58.1 Introduction
		58.2 Materials and Methods
		58.3 Processing of Samples
		58.4 Results of Samples
		58.5 Discussion
		58.6 Conclusions
		References
	Autologous Fat Transfer National Consensus Survey: Trends in Techniques and Results for Harvest, Preparation, and Application
		59.1 Introduction
		59.2 Methods
		59.3 Results
		59.4 Experience
		59.5 Technique
		59.6 Outcomes
		59.7 Discussion
		59.8 Conclusions
		References
	Medical Legal Aspects of Autologous Fat Transplantation1
		60.1 Introduction
		60.2 Requirements for Medical Negligence
			60.2.1 Duty
			60.2.2 Breach of Duty
			60.2.3 Injury
			60.2.4 Causation
			60.2.5 Standard of Care
		60.3 Informed Consent
			60.3.1 Definition
			60.3.2 Legal Definition
		60.4 Medical Record
		60.5 Legal Aspects
		60.6 Dangers in Glabellar Injection
		60.7 Blindness and Central Nervous System Injury
		60.8 Fat Transfer to the Breast
		60.9 Fat Hypertrophy
		References
	Editor’s Commentary
		61.1 Introduction
Index
                        
Document Text Contents
Page 2

Autologous Fat Transfer

Page 226

M. A. Shiffman (Ed.), Autologous Fat Transfer 223
DOI: 10.1007/978-3-642-00473-5_30, © Springer-Verlag Berlin Heidelberg 2010

30.1 Introduction

There has been some controversy about the use of auto-
logous aspirated fat for mammary augmentation. The
complaint has been that small calcifications can occur in
the breast that is indistinguishable from cancer and may
prevent the diagnosis of cancer.

30.2 Historical Contributions

Czerny (1) reported the first use of autogenous fat
(a lipoma) in breast reconstruction. Lexer (2) described
the removal of the glandular breast in a patient with
chronic cystic mastitis and reconstruction with fat rotated
from the axilla. May (3) reported on a patient with bilat-
eral breast reconstruction using a free fat autograft on one
side and a free fascia-fat autograft on the opposite side.

Bames (4) utilized fat from the buttocks denuded of
epidermis in the breast and found 40% loss of volume
because of fat liquefaction. By placing the graft with
its dermal side in contact with the breast tissue and the
fascial side in contact with the pectoral fascia, there
was about 90% graft survival. Reversal of the place-
ment resulted in 60% survival.

Peer (5) stated that dermal-fat grafts provide a readily
available transplantation material for establishing normal
contour in small breasts instead of foreign implants.

Schorcher (6) reported autogenous free fat transplan-
tation to treat hypomastia. He noted that the connective

tissue elements remained intact with fat shrinkage to
25% of the original size by 6–9 months. He believed
that if the graft was in several pieces, it would receive
better nourishment for the recipient site.

30.3 Recent History with
Liposuctioned Fat

Bircoll (7) was the first to inject autologous fat from
liposuction to augment the breast. This helped avoid the
complications of breast prostheses (8). He used small
droplets of fat (1 cc for each deposit), with a maximum
of approximately 130 cc (9).

Bircoll and Novack (10) described the use of insu-
lin to pretreat the fat in order to increase the survival
percentage. Their report concerned one patient who
had autologous fat injection into one breast to allow
better symmetry with the opposite reconstructed breast
(removed for cancer and reconstructed with transverse
abdominal rectus flap).

Asken (11) reported the use of autologous fat obtained
by liposuction to augment the hypoplastic breast. He
advised the injection of fat to be performed on with-
drawal to avoid a large amount of fat in one location.
Johnson (12) reported more than 50 augmentation mam-
moplasties performed by macroinjection from liposuc-
tioned fat. Krulig (13) reinjected fat into the breast area
and noted more than 50% resorption.

In a panel discussion at a meeting of the American
Society for Aesthetic & Plastic Surgery, Bircoll (14)
reported calcifications in three patients following
breast augmentation with fat. All were biopsied and
showed normal fat. Ousterhout (15) felt that the audi-
ence did not agree with the procedure in light of the
calcifications and stated, “….. to create calcifications

History of Breast Augmentation
with Autologous Fat

Melvin A. Shiffman

30

M. A. Shiffman
Department of Surgery, Tustin Hospital and Medical Center,
17501 Chatham Drive, Tustin, CA, 92780-2302, USA
e-mail: [email protected]

Page 227

224 M. A. Shiffman

in the breast by fat injections could cause considerable
dilemma in mammogram diagnosis and possibly a
missed malignancy diagnosis if each area of calcifica-
tion was not biopsied.”

There followed a flurry of letters in The Plastic and
Reconstructive Surgery Journal. Linder (16) stated
that fat necrosis may require removal of some of the
breast as calcifications may occur in areas of fat necro-
sis, inflammatory reaction may produce a tumor-like
mass, and “… extreme reservation should be exercised
in performing this procedure in the breast.” Ettelson’s
(17) impression was that “… preoperative and postop-
erative results both in the anterior and lateral views are
virtually interchangeable as far as I am concerned.
I am frankly shocked that the Journal would publish an
article with such an unimpressive result.” Hartrampf
and Bennett (18) had the impression that the fate of
nonvascularized fat in the breast is fat necrosis and this
causes thickening and hardening which are clinically
indistinguishable from carcinoma. Also, calcifications
can occur in areas of fat necrosis. He stated that “…
injection of any material into the breast, including
autogenous fat, should be condemned.” Baibak (19)
complained about Bircoll’s report (14) that there was
no documentation of any change in the overall appear-
ance of the patient.

Bircoll (20) responded by stating that no patient
developed hard lumpy breasts. Calcifications in two
patients occurred within 3 months of fat transplantation
and the calcifications were in the fat tissues surround-
ing the breast which is distinguished by comparison
with preoperative mammograms. Calcifications that
remain stable can be observed rather than removed and
the calcifications in areas of micronecrosis are distin-
guishable from carcinoma.

Microcalcifications occur following breast augmen-
tation with implants, open and closed capsulotomy, and
breast reduction. As a new technique, the problem of
microcalcifications in fat augmentation of the breast
should be fully evaluated and understood before discard-
ing the procedure. Bircoll (21,22) reported an estimate
of 1.4% microcalcifications following fat augmen tation
of the breast which are periparenchymal and were not
multidensity, rod-like, punctuate, or branching spicules.
Miller et al. (23) noted calcifications on mammogram in
3 (12.5%) out of 24 patients who had undergone reduc-
tion mammoplasty. These post surgical calcifications all
had a benign appearance. Brown et al. (24) reported that
there were asymmetric densities on mammograms in

approximately 50% of patients who underwent reduc-
tion mammoplasty. Out of 42 patients, a few developed
calcifications on mammogram during the first year and
over 50% had calcifications after 2 years. The calcifi-
cations were coarse and usually occurred in the peri-
areolar and inferior portions of the breast. Only one
patient with calcifications required biopsy. They con-
cluded that “knowledge of the expected mammo-
graphic alterations and their time course may help to
distinguish between postoperative change and carci-
noma, and thus eliminate the need for biopsy in some
cases.” Mitnick et al. (25) studied with mammograms
152 patients who had reduction mammoplasty. The
incidence of calcifications was 24.3%. The calcifica-
tions were mainly rounded and well formed with occa-
sional lucent center. Gradinger (26) declared that “The
use of the autologous fat injection for breast augmen-
tation as advocated by Bircoll (14) is deplored because
some patients can develop calcifications and esthetic
results are marginal.” Grazer (27) continued to denounce
the procedure when he stated that “Autologous fat graft-
ing should never be used as a breast augmentation pro-
cedure.… Calcifications have been found to be a problem
in some patients, masking malignant and prema lignant
changes. Biopsies must be performed in patients with
nodules, pain, or calcification … the aesthetic results
are marginal if large-volume augmentation is required.”
Pitman (28) opined that the “… presence of calcifica-
tions in the breasts of injected patients makes the tech-
nique unacceptable.”

The Society of Plastic and Reconstructive Surgeons
(ASPRS) produced a Position Statement on 1 October
1992, which stated that the society (ASPRS) “strongly
condemns the use of fat injections for breast enlargement,
warning that the procedure may hamper the detection of
early breast cancer, or result in a false-positive cancer
screening. Furthermore, women who seek the procedure
for breast enlargement are sometimes not informed that
much of the injected fat will die, causing scar tissue and
calcifications … In a worst case scenario, a patient may
face painful exploratory surgery or even mastectomy
because of an uncertain mammography result.”

It is this author’s opinion that medical legally it would
be a breach of the standard of care to do a “mastectomy”
because of an uncertain mammography result. Stereot-
actic needle biopsy is simple, accurate, and almost pain-
less. “Exploratory surgery” would be virtually unnec essary
in the hands of a capable and knowledgeable mam-
mographer and surgeon.

Page 452

470 Index

Peterfy, M., 30
Pflug, M.E., 341
Phenol peel, 274
Pinski, K.S., 128
Pitman, G.H., 23
Planotome, 3
Platelet-derived growth factors (PDGF), 88, 89, 91, 244–247
Platelet poor plasma (PPP), 92, 247, 248
Platelet rich plasma (PRP), 88–93, 95, 100–103, 105, 108, 110,

244–251, 446, 448
Platysmaplasty, 206
Portillo, M.P., 31
Postradiation, 318
Powell, D.M., 103, 255
Poznanski, W.J., 440
Ptosis, 80, 85, 156, 171, 203, 419, 461

brow, 85, 203
Pulgam, S.R., 419
Pulmonary emboli, 418

R
Raclot, T., 30
Radiesse, 50, 69
Ramon, Y., 140, 193, 393
Rattan, V., 363
Reston foam, 57
Restylane, 69, 161
Rhytids, 116, 117, 137, 189, 197, 217, 351
Ribeiro, M.T., 8, 394
Rieck, B., 142
Rodbell, M., 123
Roenigk, H.H. Jr., 128
Rogers, 331
Rohrich, R.J., 138, 193
Romberg, 331
Romberg’s disease, 143, 331
Roncari, D.A., 6
Rose, J.G. Jr., 193, 393
Ryden, M., 31

S
Saboeiro, A.P., 4, 226
Sadick, N.S., 142
Sakaloff, R.T., 319
Samdal, F., 7
Sattler, G., 8, 393, 403, 442
Saunders, M.C., 6, 379
Scarborough, D.A., 422
Scarpa’s fascia, 22, 23
Scars, 7, 12, 43, 63, 65–67, 72, 74, 117, 118, 159, 201, 261,

274, 327, 343, 371, 380, 394, 453, 455
acne, 69–71
hypertrophic, 71
lasers, 71

Schaeffer, I., 225
Schenk, J., 323
Schlaak, S., 142
Schorcher, F., 6, 223
Schuller-Petrovic, S., 338
Scleral show, 80
Sculptra, 50, 74

Seroma, 366, 371, 372, 418, 421
Sevchuk, O., 8
Sev’uk, O., 15, 16, 115
Shapiro, B., 6
Shiffman, M.A., 148, 442, 448
Shoshani, O., 307
Sidman, R.L., 15, 114
Signorini, M., 33
Skouge, J.W., 11, 12, 148
Sleep apnea, 376
Smith, P., 281
Smith, U., 440
Society of Plastic and Reconstructive Surgeons (ASPRS), 224
SoftForm, 197
Sommer, B., 8, 393, 403, 442
Spear, S.L., 226
Starling’s equation, 116
Starling’s Law, 125
Steatonecrosis, 102
Steed, D.L., 255
Stem cells, 446, 448
Sterodimas, A., 318
Stevenson, T.W., 155
Straatsma, C.R., 3
Subcision, 65, 67, 72, 74, 117, 190, 193
Subcutaneous musculoaponeurotic system (SMAS), 22, 422
Sulamanidze, M.A., 65
Sulcus vocalisa, 318
Superficial fascial system (SFS), 23
Superficial musculoaponeurotic system (SMAS), 136, 140,

165, 166, 169, 203, 206, 332, 412
Supraperiosteal, 213
Sweeney, G., 32
Swelling, 143, 157

T
Tear trough, 129, 138, 176, 179, 303, 399, 433
Teimourian, 13
Temporomandibular joint, 319
Thermage, 74
Thomas, B.J., 361
Tobin, H., 14
Toledo, L., 65, 114
Transsphenoidal surgery, 319
Trauma, 8, 12, 13, 116, 213, 220, 243, 248, 249, 255, 331, 445
Trepsat, F., 138
Triamcinolone, 148
Trichloracetic aicd peel (TCA), 203
Tuffier, T., 3
Tunneling, 67, 246, 249, 250, 252, 254, 256
Tunnels, 96, 101, 193, 211, 246, 250, 252, 254

U
Uebel, C.O., 15
Ullmann, Y., 8

V
van der Meulen, 155, 297
Van Harmelen, V., 31
Van, R.L., 6, 440
van Wijngaarden, H.A., 315, 358

Page 453

Index 471

Velopharyngeal, insufficiency, 357, 358, 360
Verderame, P., 3, 5, 135
Vikman, K., 30
Vitamin E, 11, 103, 255, 421
Vocal cord

paralysis, 319
scar, 319

W
Weber, K.T., 20, 128
Weber, R., 315
Wertheimer, E., 6
Wetmore, S.J., 148
White adipose tissue (WAT), 37–40
Willi, C.H., 53, 54, 297
Wolford, L.M., 319, 362

Y
Yamaguchi, M., 379
Yokota, T., 30
Yuksel, E., 105, 256

Z
Zuk, P.A., 25, 131
Zyplast, 47

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