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ORIGINAL ARTICLE
Bicompartmental Breast Lipostructuring
M. L. Zocchi Æ F. Zuliani
� Springer Science+Business Media, LLC 2007
Abstract The techniques of additive mastoplasty descri-
bed over the years require the use of alloplastic materials
(silicon), which often are poorly tolerated by the body and
need access paths that could leave visible, unaesthetic
residual scars. Furthermore, the controversy over silicone
gel-filled breast implants, which in the early 1990s
restricted their clinical use for primary cosmetic breast
augmentation, still raises concerns in some patients. The
authors therefore felt encouraged to search for alternatives
to breast implants and reconsider fat transfer. In fact, for
almost a century, autologous adipose tissue has been used
safely and with success in many other surgical fields for the
correction of volumetric soft tissue defects. Its natural, soft
consistency, the absence of rejection, and the versatility of
use in many surgical techniques have always made autol-
ogous adipose tissue an ideal filling material. In the past,
the authors used this technique, as originally described by
Fournier (intraparenchymal, en bloc injection), for 41
patients. However, disappointed by a very high rate of
complications and the almost complete reabsorption of the
grafted fat, they quit using the procedure. An extensive
literature review indicated that the complications observed
were related only to technical errors and to the anatomic
site of harvesting and implantation. The authors therefore
developed a new method incorporating recent contributions
in functional anatomy and fat transfer. Fat is harvested in a
rigorously closed system, minimally manipulated, and
reimplanted strictly in two planes only: into the retro-
glandular and prefascial space and into the superficial
subcutaneous plane of the upper pole of the breast
(bicompartmental grafting). Any intraparenchymal place-
ment is carefully avoided. Since 1998, 168 patients (300
breasts) have undergone this procedure. Grafted fat volume
has ranged from 160 to 685 ml (average, 325 ml) per
breast. Complications have been minimal and temporary.
All patients have been carefully monitored with preopera-
tive and serial postoperative mammograms and
ultrasonograms. This strict follow-up assessment allowed
the authors to clarify the controversial aspect of micro-
calcifications, the main point of criticism for this procedure
over the years. Microcalcifications can occur in response to
any trauma or surgery of the breast, but are very different
in appearance and location. Thus, they can be discrimi-
nated easily from those appearing in the context of a
neoplastic focus. Probably the most important point is that
the fat survival ranged from 40% to 70% at 1 year. The
volume is maintained because when the authors transplant
living fat tissue, they also transfer a consistent amount of
adult mesenchymal stem cells that spontaneously differ-
entiate into preadipocytes and then into adipocytes,
compensating for the partial loss of mature adipocytes
reabsorbed through time. This theory has been well dem-
onstrated via advanced research performed by the authors
and by many other prominent medical institutes worldwide.
The findings show that adipose tissue has the same
potential for growth of adult mesenchymal totipotential
stem cells of bone marrow and can eventually be differ-
entiated easily by the use of specific growing factors and
according to the needs and applications in other cellular
lines (osteogenic, chondrogenic, myogenic, epithelial). In
summary, the authors wish to highlight a formerly con-
troversial procedure that, thanks to recent technical and
clinical progress, has become a safe and viable alternative
to the use of alloplastic materials for breast augmentation
for all cases in which additive mastoplasty with implants is
M. L. Zocchi (&) � F. Zuliani
C. S. M. Institute for Aesthetic Plastic Surgery, 4, via Guarini,
Torino 10123, Italy
e-mail: michelezocchi@michelezocchi.com
123
Aesth Plast Surg
DOI 10.1007/s00266-007-9089-3
either unsuitable or unacceptable by the patient herself.
However this method cannot be considered yet as a com-
plete substitute for augmentation with implants because the
degree of augmentation and projection still is limited.
Keywords Adult stem cells � Alloplastic materials �Autologous adipose tissue � Breast augmentation �Breast lipostructuring � Fat transfer
Autologous adipose tissue has been used to correct soft
tissue defects for more than a century. Its soft and natural
texture, the absence of a line, and its versatility have
always made adipose tissue the ideal physiologic filling
material. The first surgeons using adipose tissue as a filling
material were Neuber [8], whose used it in 1893 to correct
facial defects, and Czerny [3], who used it in 1895 to treat
the sequelae of mastectomy. Since then, free grafts of
adipose tissue also have been used extensively in several
other fields of surgery including thoracic surgery (for filling
tubercular cavities), general surgery (to stop bleeding after
liver and kidney surgery), neurosurgery (for cranial defects
to obviate cerebral adherence), and orthopedic surgery (to
close bone defects).
In the 1950s, Peer [9] was the first plastic surgeon to
conduct extensive studies on the long-term survival of
autologous fatty tissue grafts. He reported that these grafts
lost more than 50% of their weight and volume after
1 year, and showed that most reabsorption occurred in the
larger fatty tissue particles and during the first 3 months
after the reimplantation.
In the 1960s, interest in autologous adipose tissue
grafting almost disappeared due to the ever-increasing use
of dermal adipose grafts, which proved to be more reliable
and long lasting. Furthermore, new artificial materials for
soft tissue augmentation (paraffin, fluid silicone, methac-
rylate, and others) became very popular despite the high
rate of complications.
Until the 1980s, fat transplantation had been performed
only as a soft tissue graft harvested en bloc with open
surgery, thus resulting in evident and ugly scars at both the
donor and receiving sites. Only in the mid-1980s did the
diffusion of syringe liposuction [4,5,12], which standard-
ized and popularized methods for harvesting fat in a simple
and safe manner, arouse renewed interest in free fat
transplantation. This has stimulated, since then, constant
evolution and technical improvement.
In 1986, Illouz [6] and Fournier [4,5] were the first to
define lipofilling as microlipoextraction and reinjection for
facial rejuvenation. Deeply involved in this field of
investigation, Zocchi [14-17] in 1989 described a method
for producing autologous collagen from fat manipulation
for face sculpting and rejuvenation. Then in France,
Fournier [4], extending his great experience and knowledge
Table 1 Limits and complications of intraparenchymal en bloc fat
grafts (old technique)
• Strong inflammatory reaction
• Steatonecrosis
• Infections
• Liponecrotic pseudocyst
• Intraparenchymal microcalcifications
• Unpredictable results due to the almost complete reabsorption
of the transplanted fat
Fig. 1 Instruments: (a)
Complete set with syringe,
syringe holders, cannulas, and
containers. (b) Special cannulas
2 mm in diameter, specially
coated. (c) Vibrating table used
for stratification of harvested
material
Aesth Plast Surg
123
Fig. 2 Functional anatomy of the
breast. ‘‘Fat constitutes more than
half of the weight of most breasts,
even small ones’’ [7]
Fig. 3 External skin expansion
with BRAVA�. (a) The
silicone-sealed cups are
positioned over the breast. (b)
The miniaturized pump is
connected. (c) The containing
bra supports the cups and pump
Fig. 4 Donor-site selection with respect to the ‘‘methameric theory,’’ which postulates that fat reimplanted on the same side (left on left/right on
right) from which it was harvested has a greater chance of survival
Aesth Plast Surg
123
Fig. 5 Surgical planning. (a)
Preoperative drawing
delimitating the reimplantation
sites on both the retroglandular
and superficial planes. (b)
Hypertrophy of the upper poles.
(c) Postimplantation touch-up.
(d) Severe hypotrophy. (e)
Asymmetry
Fig. 6 Fat harvesting
Aesth Plast Surg
123
of fat transfer to the face and other body areas, described a
personal technique of ‘‘en bloc intraparenchymal’’ fat
grafting into the breast.
From January 1991 to December 1993, we used the
Fournier technique for 41 patients, then discontinued its
use because we were disappointed with the very high rate
of complications (Table 1), and above all, with the lack of
predictability and durability due to the almost complete
ultimate reabsorption of the grafted fat. Our experience
with this old technique reflected the controversial judgment
of the international scientific community on it. Moreover,
the literature review also indicated that all the complica-
tions observed were strictly related to technical errors
during the harvesting and preparation of the fat, and most
of all, to the technique and the anatomic site of reimplan-
tation [13].
Furthermore, the well-known controversy over silicone
gel-filled breast implants (resulting in law-enforced sus-
pension of their clinical use for primary cosmetic
augmentation mammoplasty in the early 1990s, first in the
United States and then in many other countries), the non-
acceptance of having artificial alloplastic materials in the
body, and the residual scars still raise major concerns with
some patients. The result is a specific contraindication for
traditional augmentation mammoplasty.
Considering the aforementioned problems and seeking
to find safe and reliable alternatives to implants, we
developed a new technique of fat transplantation for breast
augmentation called ‘‘bicompartmental breast lipostruc-
turing’’ [20,21]. This name takes its origin from the fact
Fig. 7 Fat preparation. (a) Gentle
washing with saline solution. (b)
Stratification by vibration. (c)
Stratification by decantation. (d)
Conservation in cold saline
Fig. 8 Breast setup. (a) Antiseptic packing. (b) Nipple shield
Aesth Plast Surg
123
that fat tissue is rigorously reimplanted in two specific
anatomic areas of the breast only.
Materials and Methods
Clinical Outcome
From 1998 to 2007, 181 women with a mean age of
33 years were treated with the aforementioned technique.
All the patients underwent major or mild body con-
touring at the same time, and 60% were treated for
augmentation and volume asymmetry. Of the latter
patients, 12% had a combined reductive mastoplasty for
the contralateral breast using the ultrasound technique.
Symmetric volume augmentation of both breasts was
performed for 36% of patients, whereas 11% underwent
correction of sequelae originating from previous breast
surgery as well as augmentation (6%), reduction (2%), or
mastopexy (3%).
Instruments
A specially designed Teflon-coated cannula 2 mm in
diameter with a single lateral hole and connected to a
disposable 60-ml syringe with a tapered tip is used to
harvest the adipose tissue. A steel stopper device helps to
maintain the vacuum in the syringe during the aspiration
phase.
Two specially designed cannulas (Fig. 1a and b) with
the same features as the cannula used for harvesting are
used to perform reimplantation of the fat: a straight flexible
27-cm-long cannula for the deeper retroglandular plane and
a stiffer 25-cm-long curved one for reinjection of the fat in
the subcutaneous plane and for redefining both the breast
crease and the inframammary fold.
Fat is not centrifugated, so no centrifuge is necessary. A
vibrating table (Fig. 1c) and specially designed syringe
holders are used to speed up the cleaning phase and the
stratification process. The fat ready to be reimplanted is
then preserved in metal cylindrical containers filled with
cold saline.
Technique
We devised a new surgical technique that incorporates the
most important recent contributions in functional anatomy
of the breast [7] (Fig. 2) and fat transfer [1,2,14–17]. We
aimed to find logical solutions to all the shortcomings
observed in the earlier version of breast grafting and to
obtain more predictable and stable results. The new tech-
nique involves eight technical steps:
Fig. 9 Fat transplantation. Fat
tissue is inserted in two planes:
retroglandular (a,b) and
superficial (c,d)
Aesth Plast Surg
123
1. External breast skin expansion (using BRAVA,
BRAVA, LLC, Miami, FL)
2. Surgical planning (breast and donor areas)
3. Body contouring setup
4. Fat harvesting
5. Fat preparation
6. Breast setup
7. Fat transplantation
8. Manual reshaping.
Fig. 10 Manual reshaping. Fat
tissue is carefully molded and
reshaped to obtain a smooth and
regular surface
Aesth Plast Surg
123
External Breast Skin Expansion
The patient is asked to wear a special breast expansion device
(BRAVA) 30 days before surgery for 12 h a day. This
device, invented and distributed worldwide by the American
plastic surgeon Roger Khouri, stimulates vasculogenesis and
lymphatic activity, opening the spaces to create the ideal
situation for fat reimplantation. Unfortunately, this step
requires high patient compliance and cooperation. Because
of the discomfort in wearing the device, it is not always
accepted. Whenever patients have cooperative in wearing
BRAVA, the reimplantation phase has been facilitated and
the rate of fat survival definitively higher (Fig. 3).
Surgical Planning
In the bicompartmental breast lipostructuring procedure,
careful and precise planning of both donor (body) and
receiving (breast) areas must be performed.
Donor site (body) The donor sites selected the most often
are the trochanteric and gluteal regions, with respect, if
possible, to the homolateral receiving hemisoma (right to
right/left to left). This marking, done with the patient in the
standing position, must be adapted to the different clinical
situations (Fig. 4).
Table 2 Rating of the aesthetic results
Results Patients
(n)
Evaluation
(%)
Surgeon
(n)
Evaluation
(%)
Insufficient 5 3 10 6
Fair 10 6 25 12
Good 128 72 123 69
Excellent 38 23 23 13
Table 3 Complications of bicompartmental lipostructuring
N %
Edema 181 100
Bruising 143 78
Dysesthesia 14 5.8
Liponecrosis 2 1.2
Microcyst 3 1.8
Microcalcifications 7 3.9
Table 4 Radiologic follow-up evaluation
• Sonography, preoperative, 6 months, 1 year
• Mammography preoperative, 1 year (Fig. 11)
• Magnetic resonance imaging (MRI) on demand (Fig. 11)
Fig. 11 Mammography. (a)
Before bicompartmental breast
lipostructuring. (b) Enlarged
volume of the adipose prefascial
plane (radiotrasparency) after
1 year. (c) Magnetic resonance
imaging (MRI) showing
enlarged breast with normal
healthy fat before surgery and
(d) 1 year after surgery (R.
Khouri)
Aesth Plast Surg
123
Receiving site (breast) The most empty areas of the
superior quadrants and any volume asymmetry or dis-
crepancy in height and position of the submammary fold
are carefully marked preoperatively on the breast while the
patient is in the standing position (Fig. 5).
Body-Contouring Setup
The bicompartmental technique often is used as a com-
plement to extensive circumferential body-contouring
surgery (ultrasonic lipoplasty). The patient is first disin-
fected in the standing position with a nonalcoholic solution
to reduce the chance that the preoperative marking will be
wiped off. General anesthesia then is induced on a surgical
sterile bed. After the patient has been turned in the prone
position onto another adjacent sterile bed, the areas to be
treated are infiltrated with room-temperature saline using
2 mg of adrenaline per liter, usually starting from the left
side of the body.
Fat Harvesting
Fat is harvested in a rigorous closed system using dispos-
able tapered-tip 60-ml syringes and a 2-mm single-hole
Teflon-coated special cannula (Fig. 6). The fat tissue usu-
ally is harvested only in the posterior areas of the body,
with care to avoid, whenever possible, the inner face of the
thighs and the abdominal area. During the harvesting
phase, the surgeon must constantly remember to avoid
creating asymmetries or irregularities at the donor sites.
The relevant quantity of fat necessary for a bilateral breast
lipostructuring is based on extensive knowledge
concerning the principles of traditional body contouring
and a respect for all its technical steps (planning, infiltra-
tion, deep plane, superficial plane).
Fat Preparation
After the harvesting phase, the fat tissue is prepared with
minimal manipulation. A gentle washing with saline solution
in the same syringe used for harvesting is done to remove all
undesirable components (blood, saline, oil) (Fig. 7a).
During the preparation phase, the syringes full of har-
vested fat tissue are maintained in an upside-down position
with specially designed syringe holders. Then the syringes
are placed for 30 s on a sterile vibrating device to speed up
the stratification process, leading to separation of the har-
vested material into two main layers: fat tissue and fluid
(Fig. 7b and c).
Centrifugation is not necessary and not recommended in
this procedure. Handling such a large quantity of fat for
reimplantation (up to 2,000 ml) would dramatically
increase the duration of this step. Furthermore, the centri-
fugation phase of 5 min at 3,000 rpm, as described by
Coleman [1–3], has been demonstrated to increase the
apoptotic death rate for adult mature adipocites. [10,14–
17]. After preparation, the harvested adipose tissue is
preserved in the same syringes used for harvesting plunged
in cold saline (Fig. 7d).
Breast Setup
Once the harvesting and the body-contouring phases are
completed in the posterior areas, the patient is turned over
Fig. 12 (a–c) Preoperative
views of a 30-year-old woman
with a severe breast hypotrophy.
(d–f) Postoperative views
2 years after a bicompartmental
breast lipostructuring procedure
that reimplanted 290 ml of
adipose tissue in each breast
Aesth Plast Surg
123
on the surgical table and placed in the supine position for
completion of the anterior body contouring and for the
breast lipostructuring. During all this time and until the
moment of reimplantation at the very end of the surgery, an
iodine solution (Betadine) packing is applied to the breast
area. The nipples are protected by adhesive nipple shields
to avoid any contamination of the grafted area by acci-
dental spreading of glandular secretions, often at the origin
of inflammatory and infectious reactions (Fig. 8).
Fat Transplantation
Fat is reimplanted through a small incision made with a no.
11 blade in the medial portion of the inframammary fold.
Two specially designed self-lubricated 2-mm cannulas are
used for this step: a straight flexible 27-cm-long cannula
for the deeper retroglandular plane and a stiffer 25-cm-long
curved one for reinjection of the fat in the subcutaneous
plane and for redefining the breast crease and the infra-
mammary fold. The fat transplantation technique is
performed only into the retroglandular/prefascial plane and
into the superficial subcutaneous tissue of the upper pole of
the breast (bicompartmental grafting) in hundreds of ret-
rograde paths, with care to avoid any intraparenchymal
placement.
After insertion, the cannula should stay parallel to the
chest-wall and then proceed upward through the retro-
glandular space, always in touch with the pectoralis
aponeurosis until it reaches the superior preoperative marks
(Fig. 9a), As its tip goes beyond the gland, keeping on the
same level in this area, it actually ends up being in the
subcutaneous plane. The first fat-filled syringe is connected
(Fig. 9b). The assistant’s hand should be used as a barrier
to prevent any accidental spreading of fat in undesired
areas.
Fig. 13 (a–c) Preoperative
views of a 23-year-old woman
with moderate upper pole breast
hypotrophy. (d–f) Postoperative
views 1 year after a
bicompartmental breast
lipostructuring procedure that
reimplanted 310 ml of adipose
tissue in each breast
Aesth Plast Surg
123
After completion of fat insertion behind the gland, the
adipose tissue is injected along the inframammary crease
and the breast medial border. At this time, a curved
cannula should be used to allow grafting along the
rounded outline. The curved cannula is kept in a strictly
subcutaneous plane and must be rotated by 90�. At
the end, its tip will be oriented upward, with its hole
facing the dermis, to prevent fat from being injected too
deeply.
The adipose tissue is injected as the cannula is with-
drawn. The amounts should be limited to the bare
minimum needed to fill up the tunnels left by the cannula
(i.e., 2–3 ml of fat for each tunnel). Any excess could
determine surface irregularities. At the end of the proce-
dure, the incision must be meticulously and tightly sutured
with a reabsorbable thread (Fig. 9a–d).
Manual Reshaping
Next, implanted fat tissue is carefully distributed to obtain
a very regular and smooth surface. The aim of this
important and delicate phase is to reproduce the shape of an
anatomic implant, especially in the upper pole, where it is
important to create a natural and physiologic fullness,
avoiding excessive roundness or unaesthetic stepping.
Once fat grafting has been completed, the adipose tissue
is redistributed and molded so as to flatten out any irreg-
ularity along the borders. About 10 ml of Vaseline oil are
used as a lubricant. This maneuver, performed using both
fingertips and the radial edge of the hand, requires much
pressure, but does not damage the adipocytes because
compression is exerted on the tough bony surface rather
than on the grafted fat itself.
Fig. 14 (a–c) Preoperative
views of a 44-year-old woman
with moderate upper pole breast
hypotrophy. (d–f) Postoperative
views 1 year after a
bicompartmental breast
lipostructuring procedure that
reimplanted 300 ml of adipose
tissue in each breast
Aesth Plast Surg
123
Peripheral squeezing maneuvers are performed along
the marked curved mammary outline while the whole
breast surface is carefully checked for detection of any
superficial unevenness. It should be noted that all this
will not displace the fat in undesired areas because the
latter has been inserted following crisscross vectors.
Consequently, septa of connective tissue act as a barrier,
preventing any adipose tissue from sliding beyond the
traced breast border. This desirable ‘‘fence’’ effect will
last during the whole healing process. At the end of the
treatment, an elastic roll is fixed to maintain the space
between the breasts, and a sports bra with shaped cups
and no wire is used to support the breast for 4 weeks
(Fig. 10a–g).
Fig. 15 (a–c) Preoperative
views of a 42-year-old woman
who underwent surgery 2 years
previously for a round-block
mastopexis presenting with a
moderate loss of volume in the
upper poles of the breast,
insufficient projection of nipple-
areolar complex, and diffused
skin irregularities. (d–h)
Postoperative views 6 months
after a bicompartmental breast
lipostructuring procedure that
reimplanted 350 ml of adipose
tissue in each breast
Aesth Plast Surg
123
Results
Since 1998, a total of 181 patients have undergone the
aforementioned procedure (145 bilateral and 36 monolat-
eral), for a total of 326 breasts. Grafted fat volume has
ranged from 160 to 745 ml (average, 375 ml) per breast.
Volume persistence at 1 year was up to 70% (average,
55%). It is noteworthy that transplanted fat reabsorption
was significantly reduced, thanks to the improved har-
vesting and grafting technique and, above all, to the choice
of reimplantation site.
A few patients who had undergone simultaneous
extensive body contouring (ultrasonic megalipoplasty) and
had lost significant weight after the surgery sometimes
Fig. 16 (a–d) Preoperative
views of a 54-year-old woman
showing a severe loss of volume
in the upper poles of the breasts,
poor definition of the mammary
crease, and asymmetries 6 years
after reductive mastoplasty. (e–
h) Postoperative views
6 months after a
bicompartmental breast
lipostructuring procedure that
implanted 500 ml of adipose
tissue in the left side and 400 ml
in the right side
Aesth Plast Surg
123
complained about an insufficient volume increase. More
often, patient satisfaction was higher than surgeon satis-
faction (Table 2).
The most common side effects during the first 2 weeks
after surgery were localized edema and slight bruising.
Overall, complications (Table 3) were minimal and tem-
porary. Three cases of pseudocysts resolved spontaneously
over a period of 6 months. In a series of 171 patients
treated with the described procedure during an 8-year
period, to date, only 6 cases of microcalcifications have
been monitored (rate of 3.9%): one bilateral in the upper
pole and the others unilateral in the prefascial retroglan-
dular plane.
All the patients were carefully monitored with preop-
erative and serial postoperative mammograms and
ultrasonograms (Fig. 11). This close follow-up evaluation
allowed us to clarify the most controversial aspect of
microcalcifications, which has been the main point of
criticism for this procedure over the years.
Microcalcifications cannot be completely prevented, and
they can occur in response to any trauma or surgery to the
breast. However, they are very different in appearance and
location and generally can be distinguished easily from
those appearing in the context of a neoplastic focus. For
instance, it also is very important to clarify that all the other
breast surgeries lead to the formation of microcalcifica-
tions, with the highest rate (\15%, Sadove [11]) related to
reduction mammoplasty.
A correct radiologic follow-up assessment (Table 4) and
a meticulous record of the surgical procedure usually have
been sufficient to clear any diagnostic concern. Good
communication with the radiologists is mandatory. In those
rare instances of persistent doubt, we could be confronted
by a false-positive, and although this generates distress in
Fig. 17 (a–c) Preoperative
views of a 56-year-old woman
with too visible breast implants,
insufficient soft tissue coverage,
and poor crease definition. (d–f)Postoperative views 2 years
after a bicompartmental breast
lipostructuring procedure that
reimplanted 300 ml of adipose
tissue in each breast
Aesth Plast Surg
123
the patient, it can be easily clarified with a simple tridi-
mensional (stereo-tassic) biopsy.
Clinical Experience
Figures 12, 13, 14, 15, 16, 17, 18
Conclusions
Current techniques for augmentation mammoplasty involve
the use of alloplastic materials and an open approach. The
former may not be well tolerated and often can be the
origin of undesirable effects such as capsule contracture.
The latter implies residual scars, which can sometimes be
less than satisfactory from an aesthetic point of view.
Constant research in this field, progressive improvement
in design and biocompatibility of breast implants, and the
evolution of surgical techniques have led to shorter and
better-hidden scars, reducing, however, only partially all
the aforementioned shortcomings and problems. Further-
more, the well-known controversy over silicone gel-filled
breast implants, which in the early 1990s resulted in a
suspension of primary cosmetic augmentation mammo-
plasty from clinical use in the United States, has not been
completely overcome, and still raises concerns with some
patients.
A thorough review of the literature suggests that all the
common complications observed in the past can be attributed
to methodologic errors, mainly related to the technique for
harvesting and to the anatomic site of reimplantation. There
is no evidence or proof of specific problems related to the
intrinsic features of the fat tissue itself as augmentation
material. In fact, the use of fat for correction of volumetric
soft tissue defects is almost 100 years old, first accomplished
with an open surgical approach and then with less invasive
techniques. Its softness, good tolerance by the body, and
versatility in many clinical situations make fat the most
desirable autologous filler material.
Therefore, we wish to call the attention of the interna-
tional scientific community to a controversial and, in the
past, abandoned procedure. All recent technical and clini-
cal advances have minimized complications and
dramatically increased transferred fat survival and volume
persistence. If well done, bicompartmental breast lipo-
structuring can be the most viable and safe alternative to
the use of prosthetic material for breast augmentation in
selected cases (Table 5). It offers to both patients and
surgeon many benefits and advantages (Table 6).
A very common observation is the fact that the majority
of the patients treated with bicompartmental breast
Fig. 18 A very interesting case of a 20-year-old woman. At the age
of 15 years, she underwent an augmentation mammoplasty of the left
breast only to correct a severe hypoplastic left breast and the related
asymmetry. At first observation, the patient showed a severe
asymmetry with excessive volume of the left breast. The patient also
complained of stiffness, irregularities of profile, and contraction of the
left breast (a). The implant was removed (b–d), and after 6 months,
extensive lipoplasty of the body and bi-compartmental breast
lipostructuring was performed to reimplant 435 ml of adipose tissue
in the left breast only. View 1 year after surgery (e,f)
Aesth Plast Surg
123
lipostructuring present with consistently improved skin
quality in terms of both elasticity and texture. Skin stretch
marks, especially in the lateral area and around the nipple-
areola complex, very often are less evident. This evidence
confirms that the transfer of fat tissue acts not only as a
volume replacement, but also as a tissue regenerator. This
observation is supported by the most recent studies on adult
stem cells contained in adipose tissue, conducted by us and
others groups worldwide [2,18,19].
The most advanced research has been able to demon-
strate that adipose tissue presents the same high potential of
growth as mesenchymal totipotential bone marrow stem
cells. However, the harvesting of bone marrow is definitely
more traumatic and limitative. In contrast, adipose tissue
can represent an inexhaustible source of easy and imme-
diately available mesenchymal cells for clinical application
in all areas of medicine that care for the regeneration of
autologous tissue. In fact with a modest quantity of adipose
tissue, we have demonstrated that it is possible to obtain,
through rigorous isolation and culture techniques, a large
quantity of totipotential stem cells that can eventually be
differentiated easily according to various needs (adipose,
cartilaginous, bone, endothelial, muscular, hepatic tissues
and pancreatic cells).
For all the aforementioned benefits, if well performed
following all the technical steps, bicompartmental breast
lipostructuring should be considered a safe and viable
alternative to traditional augmentation mammoplasty for
all cases in which additive mastoplasty with implants is
either unsuitable for the patient or unacceptable to her.
However, it is not our intention to propose this method as a
complete substitute for breast augmentation with alloplas-
tic implants. The achievable volume and projection of the
mammary cone still are limited, even if augmentation is
mainly localized at the upper pole, the most critical area of
early aging and volume loss.
References
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Table 5 Indications for bicompartmental breast lipostructuring
• Contraindications or refusal of implants
• Moderate volume expectation
• Moderate mammary ptosis
• Volume loss in mammary upper pole
• Asymmetries
• Implant irregularities (wrinkles, steps, rippling)
• As a complement of a body contouring
Table 6 Benefits of bicompartmental breast lipostructuring
• Minimally invasive procedure
• Unnoticeable scar
• Realizable in local anesthesia
• Short recovery
• Ideal complement to a body contouring procedure
• Push-up effect
• Natural look
• Natural touch
• Improved quality of skin texture
Aesth Plast Surg
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