Daniel A. Del Vecchio

A classification of clinical fat grafting: different problems, different solutions.

Background: Fat grafting has reemerged from a highly variable procedure to a technique with vast reconstructive and cosmetic potential. Largely because of a more disciplined and scientific approach to fat grafting as a transplantation event, early adopters of fat transplantation have begun to approach fat grafting as a process, using sound surgical transplantation principles: recipient preparation, controlled donor harvest, time-efficient transplantation, and proper postoperative care. Despite these principles, different fat grafting techniques yield impressive clinical outcomes. Methods: The essential variables of four types of fat grafting cases were identified and compared: harvesting, methods of cell processing, methods of transplantation, and management of the recipient site. Results: Each case differed for most of the variables analyzed. The two clinical drivers that most impacted these differences were the volume demands of the recipient site and whether the recipient site was healthy tissue or pathologic tissue. After these two drivers, a matrix classification of small-volume versus large-volume and regenerative versus nonregenerative cases yields four distinct categories. Conclusions: Not all fat grafting is the same. Fat grafting, once thought to be a simple technique with variable results, is a much more complex procedure with at least four definable subtypes. By defining the essential differences in the recipient site, the key driver in fat transplantation, the proper selection of technique can be best chosen. In fat transplantation, different problems require different solutions. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Composite breast augmentation: soft-tissue planning using implants and fat

Background: A variety of suboptimal results arise in breast augmentation due to failure of the overlying soft tissue to adequately cover the implant. The authors describe a new concept of composite breast augmentation surgery that combines the core volume projection of breast implants with the natural look and feel of overlying fat. Methods: A total of 197 patients were treated over a 3-year period. This new approach was used when the overlying soft tissue was thin or insufficient to adequately cover the underlying prosthesis, in both breast implant revision and primary breast augmentation. In a subset of cases, quantitative three-dimensional breast imaging evaluated transplanted fat volume in the subcutaneous space of the breast. In primary cosmetic augmentation cases, preexpansion was not performed. In revision cases, preexpansion was performed to support the desired volume of fat required to achieve the aesthetic result. In a second subset of patients, preoperative and 1-year postoperative mammograms were evaluated by breast radiologists. Results: Fifty-seven percent of the volume of graft injected persisted at 1 year. Because fat provided soft-tissue implant coverage, there was less need to place the prosthesis beneath the muscle; many implants were placed in the subfascial plane. Evaluation revealed no cysts, masses, or fat necrosis, presumably because the recipient site was not overloaded with fat. Conclusions: Breast augmentation with simultaneous implants and fat affords a more powerful and versatile approach, and achieves a synergistic outcome. Composite breast augmentation should be added to the list of applications where fat grafting to the breasts may have clinical utility beyond simple core volume enhancement.

SIEF--simultaneous implant exchange with fat: a new option in revision breast implant surgery.

Summary: A technique of implant exchange is reported using recipient-site preexpansion followed by autologous fat transplantation to the breast in 12 consecutive patients with breast implants who desired implant removal. Recipient-site preexpansion, used 2 weeks before fat grafting, may have both practical and theoretical benefits in increasing the breast subcutaneous space and stimulating the recipient-site microcellular environment overlying the prosthetic implant, allowing the subcutaneous insertion of a sufficient core volume of donor graft at the time of prosthetic explantation. In the cases described, the postexplantation breast volume at 9 months to 1 year postoperatively by quantitative three-dimensional imaging was equal to or greater than the preexplantation composite volume of breast and implant. Preexpansion before implant exchange with fat affords a more abundant space, completely independent from the subglandular or submuscular planes. In this new space, the “third space” of the breast, it is possible to technically place graft into the breast subcutaneous tissue and alleviate breast asymmetry resulting from pocket distortions caused by capsular contracture or by implant pocket drift. Observing breast augmentation with implants and with fat grafting in the same patient affords a unique opportunity to analyze some of the key differences between the two techniques. Recipient-site preexpansion and simultaneous implant exchange with fat (SIEF) should be added to the list of applications where fat grafting to the breasts may have early clinical utility and portends the use of fat used in conjunction with breast implants to achieve better patient outcomes. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.