Autologous breast augmentation
The use of autologous fat for aesthetic breast enlargement can provide natural results, with an added benefit of shaping
from liposuction. Dr Amin Kalaaji, Cecilie Bergsmark Bjertness and Dr Kjell Olafsen describe their study comparing
machine and manual centrifuge fat grafting methods for breast augmentation
Much progress was made in the field of medicine during the Greco-Roman period, documented in ancient texts which were
disseminated throughout civilisation. It was during this period that Roman medical writer Aulus Cornelius Celsus wrote De
Medicina, which described surgical methods for reconstructing ears, lips and noses. The first nasal reconstructions using a
forehead flap were performed by Sushruta in India between 600–700 BC.
During the early Byzantine era, Oribasius compiled a compete medical encyclopedia entitled Synagogue Medicae. This 70-volume
work contained numerous passages dedicated to reconstructive techniques to repair facial defects.
A fifteenth century Islamic text by Serafeddin Sabuncuoğlu, Imperial Surgery, was largely based on Abulcasis’ 10th Century work
Al-Tasrif. However, Sabuncuoğlu introduced many innovations of his own, including material on maxillofacial surgery and eyelid
surgery, as well as a protocol for the treatment of gynaecomastia. This is believed to be the foundation for the modern method of
surgical breast reduction.
Around the time of World War I, surgeons began to fully realise the potential influence that one’s personal appearance could exert
upon the degree of success experienced in his or her life. Because of this understanding, aesthetic surgery began to take its place
as a more respected aspect of plastic surgery.
In 1907, Dr Charles Miller penned the first text specifically written on cosmetic surgery, entitled The Correction of Featural
Imperfections. The text, while ahead of its time in some respects, was nonetheless criticised and denounced as “quackery” by
many general surgeons.
Unfortunately, this attitude was prevalent among the medical community, who largely tended to view cosmetic surgeons, including
Dr Miller, as charlatans or “quacks”.
Fat grafting
In 1895, surgeon Vincenz Czerny carried out the earliest breast augmentation/reconstruction when he used the patient’s
autologous adipose tissue, harvested from a benign fatty lumbar lipoma, to repair the asymmetry of the breast from which he had
removed a tumour.
The use of autogenous abdominal fat to correct deficits in the malar area and chin was reported in 1909. Throughout the early part
of the 20th century, attempts were made to correct other conditions, including hemifacial atrophy and breast defects, but modern fat
grafting did not develop until the early 1980s with the popularity of liposuction.
In 1984, Dr Yves-Gérard Illouz reported the transfer of liposuction aspirate fat and in 1986, Dr Richard Ellenbogen used free pearl
fat autografts in atrophic and post-traumatic facial deficits. Fat grafting has become popular for a variety of problems including
facial scarring, lip augmentation and facial rhytides—such as the nasolabial fold and glabellar furrows. Dr Sydney Coleman has
since developed the technique of fat grafting, and also invented the so called Coleman injections canulaes which carried his name,
particularly for facial treatments.
Fat grafting is now a well-known clinical method for reconstruction of small defects and has recently been applied to the face, but to
lesser extent for breast reconstruction and only recently to aesthetic breast augmentation as an alternative to breast implants.
Since 2008, the Oslo Plastikkirurgi Clinic in Norway has carried out 49 breast enlargements in 43 patients with fat grafting to treat
hypoplasia mammae, asymmetry and in combination with other procedures like abdominoplasty and mastopexy.
Patients need to fulfill five criteria to become a candidate for surgery. The patient must not want a foreign object to be used; they
must have existing fat to be corrected, not just a donor site—no hunting for fat. The patient must also have realistic expectations of
breast volume increase. A result from fat grafting will never be as voluminous as with breast implants.
There must be no breast cancer history and the patient must have a normal ultrasound or MRI before the operation, and agree to
have another examination one year post-surgery.
Methods
Of the 49 enlargements performed at the clinic, we carried out a study comparing machine and manual centrifuge for fat grafting.
In the first group (28 enlargements), the fat was machine-centrifuged for three minutes, while a manual centrifuge was used on the
other group of patients (21 enlargements). Fat was usually harvested from the abdomen, thigh, buttocks or knee and was grafted in
intersecting and parallel canals through small incisions using Coleman’s cannulas.
In the machine-centrifuged group, the fat was treated with 3000 rounds per minute. The fat was then separated from the liquids and
oil, and filled in 10ml syringes. Using a 1.5–2ml Coleman cannula, the fat was mostly injected subglandularly.
In the manual group, we used a manual centrifuge rotated by hand, usually carried out by the nurse. The fat was sampled in a 60ml
syringe and rotated around a spine for three minutes. This method has 15G gravitational force, compared to 1200G for the machine
centrifuge. It is thought that this method is less distracting for the fat than the machine method.
The procedure is performed under total intravenous anaesthesia (TIVA) and local anesthesia corresponding to the standard
concentration used in liposuction. Using 3–4 ml cannulae for harvesting the fat and avoiding maximal pressure when injecting
the local anaesthesia are important factors, as we are trying to avoid injuring the fat cells. A local anesthetic is also used when
undermining the breast area where the fat is to be grafted.
Areas of liposuction, as well as the amount of extracted and injected fat, should be agreed with the patient before the procedure.
We also advise patients not to lose weight after the operation. A loose bra is used postoperatively and there should not be any
pressure on the injected side of the breasts—this will increase absorption and compromise the circulation to the fat.
Before & after photos of a 31-year old patient with moderate hypoplasia and slight asymmetry, resulting in the right breast being smaller than the left. Fat was
harvested from the thigh. A total of 175ml of fat was grafted in the right side and 150ml in the left. A,B: Front view before and after. C,D: Right view before and after.
E,F. Left view before and after
Results
In the machine-centrifuged group, the average follow up time was 15 months and for the manual group, one year. Average injected
fat in the machine and manual groups was 206ml and 229ml respectively in the left breast, and 204ml and 234 ml in the right.
Resorption rate was less than 50% in the main part of patients in both groups (72% of the patients in the machine group and 83%
in manual group). Ten patients were not satisfied because resorption was more than 50%—seven in the machine group and three
in the manual. New injections were performed on six patients.
Three patients chose to have breast implants following the procedure because there was not enough donor fat and/or because
their expectation of breast volume with this method was not fullfilled. One patient was surprised with the expected breast volume
but was interested in gaining even more volume with implants. Two small cysts were treated easily and one minor fat necrosis was
observed in a mastopexy case along with the scar.
According to Khori, fat grafting can be characterised by the four S’s farmer analogue of sowing seeds in a field: seeds (harvesting
of fat cells), soil (preparing the breasts), sowing (grafting technique) and support (post-operative care). Each step is rate limiting
and the weakest link could determine the outcome.
Patients should be aware about overcorrection of the breast which, along with swelling, gives the impression of being bigger than
normal. To avoid disappointment, patients should be informed that overcorrection and swelling—seen directly after the operation—
is not the final result and that they should always compare pre-operative photos with results.
In our study, patients obtained a natural feeling, more fullness in desired areas, such as the upper side of the breast, correction
of asymmetry, and removal of unwanted fat and corrected areas. There is also no risk for capsular contractions, which we see in
breast implants.
However, far from all patients obtained the desired volume. Furthermore, it is difficult to calculate gained rest volume. Vectra
3D imaging is used to determine the breast volume, but this is still in the establishment phase. Factors like centrifugation, local
anaesthetics, cannulas used, preoperative expansion and the injected fat amount still have an unclear interaction on the result.
Stromal vascular fractions and adipose derived stem cells (ADSC) are explosive research areas, which could affect the outcome
of fatgrafting. The BRAVA expansion device invented by Khori could also be used, especially in the severe hypoplasy, though it is
essential for breast reconstruction.
Providing strict patient selection is carried out, this method could be a good alternative for breast enlargement for patients who
never want implants, for correction in asymmetry, Poland syndrome, in combination with other procedures like abdominoplasty, and
even as a composite augmentation together with implants.
This is tissue engineering. It is strongly not recommended for non-plastic surgeons and definitely not for beginner plastic
surgeons. This technique is reserved only for experienced plastic surgeons with experience of handling tissue, bearing in mind
the armamentarium of treatment. Failing to do so would risk undermining results and the technique as a whole. However, a longer
follow- up time and multicentre studies should be performed before final conclusions can be made.
Dr Amin Kalaaji, medical student Cecilie Bergsmark Bjertness and Dr Kjell Olafsen practice at the Plastikkirurgi Clinic in Oslo,
Norway. W: www.osloplastikkirurgi.no E: [email protected]
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