1
Title of the article:
Fat injection to the breasts: cosmetic augmentation, implant replacement, inborn
deformity, and reconstruction after mastectomy
Authors:
Kotaro Yoshimura, M.D.,1 Yuko Asano, M.D.2
Affiliations:
Department of Plastic Surgery, University of Tokyo School of Medicine;
7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
2
Cellport Clinic Yokohama;
Yokohama Excellent III Building 2F, 3-35, Minami-nakadori, Naka-ku, Yokohama,
Kanagawa 231-0006, Japan
1

Corresponding author:
Kotaro Yoshimura, M.D.
Department of Plastic Surgery, University of Tokyo School of Medicine;
7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan
Telephone: +81-3-5800-8948; Fax: +81-3-5800-8947
E-mail: yoshimura-pla@h.u-tokyo.ac.jp

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Summary/Key points· Moderate augmentation (100-200 ml) of the breast is successfully achieved byautologous lipoinjection without major complications if appropriately performed inselected patients.
· Breasts augmented with fat injection are soft and show natural texture and appearance,and patients are free from daily stress and future concerns derived from foreign materials(such as complications and potential implant replacement or removal).
·Surviving fat volume varies substantially among patients, and multiple factors are likely
to affect the clinical results; patient factors include skin redundancy of the breast, quality(such as viability and progenitor richness) of fat grafts, and infiltration techniques are key
determinants to clinical results of lipoinjection.
· Aspirated fat tissue should be appropriately harvested and stored, and quickly processed
and infiltrated with proper devices to avoid degradation of the graft tissues and to placealiquots of fat grafts as diffusely as possible.
· Relative deficiency of adipose progenitor cells in aspirated fat tissue may lead to longterm atrophy of the grafts, and supplementation of vascular stromal fraction containing
adipose progenitor cells may boost the efficacy and safety of lipoinjection to the breasts.

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I. Introduction
Autologous fat transplantation is one of the promising cosmetic treatments for facial
rejuvenation and soft-tissue augmentation due to the lack of incisional scar andcomplications associated with foreign materials. However, certain problems remain, suchas unpredictability and a low rate of graft survival due to partial necrosis. It has also beenused in breast augmentation by a limited number of plastic surgeons [1], although the useof autologous fat for breast augmentation has been controversial due to the lack ofconsensus on whether it is safe and appropriate because of microcalcifications that may
cause confusion in the evaluation of mammograms.
Implantation of prostheses has been a golden standard for breast augmentation, but
complications with artificial materials such as capsular contracture remain to be resolved.
The presence of the implant and capsules induced by implants could also affect breast
tissue visualization in the mammogram [2]. Furthermore, there is potential for rupture
when pressure is exerted on the implant during mammography, and for this reason,
hospitals in Japan reject women with breast implants to undergo mammography as a partof annual social health examinations. Recently, autologous fat injection has been reevaluated as a potential alternative to artificial implants for breast augmentation [1,3]. This
re-evaluation may reflect recent advances in autologous fat transfer and the radiologicaldetection of breast cancer.
In this chapter, potentials of fat injection for breast augmentation or reconstruction
are discussed as well as our novel approach of autologous fat grafting called cell-assisted
lipotransfer (CAL) [3,4], which is concurrent transplantation of aspirated fat tissue andadipose progenitor cells.
II. Patient selections
There seems to be several patient factors which may affect the clinical result of
conventional lipoinjection or CAL; skin redundancy of the breasts, age, BMI, personalquality or character of fat tissue, adhesive scars, breast implant and its capsule, systemic
disease such as autoimmune disease, oral corticosteroid, etc [3,5]. Good candidates arethose who have sufficient fat at donor sites and the redundant breast skin with healthyvascularity and without any scars.
Lipoinjection can be performed in any patients from teens to seventies, but patientswith small BMI (less than 17) or athletes with little body fat are not good candidates due
to difficulty in harvesting a large volume of fat tissue. Patients, who want a large-volume(250-400 ml) augmentation, are not good candidates because augmentation volume
achieved by a single session of lipoinjection is limited (100-200 ml).
Some patients are concerned about complications derived from foreign bodies andabout possible surgical removal or replacement of implants in the future. Others do notwant their history of breast surgery to come out. These patients want to avoid breast
implants and do not usually persist in size of breast augmentation; they are one of goodcandidates for this procedure.
III. Indications
Operative indications are described below according to three kinds of graft tissue
preparations or operative purposes.

41) Graft tissue preparations
As for lipoinjection, we have a conventional lipoinjection (micro-fat grafting) and a
new technique; grafting of progenitor-enriched adipose tissue. We call the latter cellassisted lipotransfer (CAL); the concept and details of CAL is described later. There are
two types of CAL, mini-CAL and full-CAL; only a fluid portion of liposuction aspirates
are used for harvest of adipose progenitor cells in the mini-CAL, while another similar
volume of liposuction aspirates to graft tissues are used for the cell isolation in the fullCAL (Fig. 1). Thus, full-CAL requires a twice volume of adipose tissue as theconventional lipoinjection or mini-CAL; approximately 700-800 ml lipoaspirates areneeded for conventional lipoinjection or mini-CAL for both breasts, while 1200-1500 ml
lipoaspirates are required for the full-CAL procedure.
If BMI is less than 18 or body weight is less than 45 kg, conventional lipoinjection
or mini-CAL is recommended. On the other hand, for patients with BMI over 25, fullCAL is easily performed without concerns on her donor site.
2) Operative purposesA) Breast augmentation
Lipoinjection can be performed without combining any procedures. We, however,also propose a secondary lipoinjection after one-year implantation of breast prostheses ifpatients are very thin, have flat breasts and tight breast skin, because only a less volume
lipoinjection can be performed in those cases due to high internal pressure and skintension after injection.
B) Breast implant replacement
Lipoinjection can be performed at the same time with implant removal. The implants
have to be removed through a peri-areolar incision, though they can be removed throughan axillary incision if lipoinjection is performed separately from implant removal.
C) Breast reconstruction
Lipoinjection can be performed in any cases, but detailed assessment of tissue andskin conditions of the breasts is necessary before application. In most reconstruction caseswith skin shortage, lipoinjection after tissue expansion is recommended; lipoinjection canbe performed immediately after removal of the tissue expander. For patients who havesufficiently redundant skin and do not have severe scar tissue or adhesion of the skin to theunderlying fascia or any other deep tissues, lipoinjection alone may successfully work.
Lipoinjection can be applied to patients with the irradiated skin, though the injection
volume is usually limited. A few or several sessions of lipoinjection can be performed tothe irradiated breasts with each interval of more than 12 months. Lipoinjection after tissue
expansion is also applied to those irradiated patients, but expander implantation under the
pectoralis major muscle and a careful expansion are recommended.
D) Inborn deformity
Simply hypoplastic breasts can be successfully treated with lipoinjection in mostcases, but tubular deformity is hard to be improved by lipoinjection alone. Funnel chest
can be corrected with lipoinjection, though the filling volume by a single surgery islimited and repetitive treatments are usually recommended.

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IV. Injection of progenitor-enriched fat tissue: principles and therapeutic concepts ofcell-assisted lipotransfer (CAL)
1) Cell components of adipose tissue
Adipose tissue consists predominantly of adipocytes, adipose stromal cells (ASCs),
vascular endothelial cells, pericytes, fibroblasts and extracellular matrix [6]. Adipocytes
constitute more than 90% of tissue volume, but they are much larger in size than othercells above and the number of adipocytes is estimated to be less than 50% [7] (Fig. 2).
ASCs are considered to be adipose tissue-specific progenitor cells (adipogenic andangiogenic progenitors), a part of which have been shown to differentiate into multiple
lineages and are now called adipose-derived stem cells [8]. ASCs contribute to adipose
tissue turnover (adipose tissue is considered to turn over every 2-10 years [9,10]) andprovide cells in next generation. ASCs are currently being used in various clinical trials,
including treatments for rectovaginal fistula (autologous cultured ASCs) [11] and graftversus-host disease (non-autologous ASCs) [12] If ASCs are harvested from a large
volume (e.g. 500 ml) of liposuction aspirates, ASCs can be used clinically without cell
expansion because a sufficient number of cells can be obtained. The use of minimallymanipulated fresh cells may lead to higher safety and efficacy in actual treatments.
2) Aspirated fat tissue vs. intact fat tissue
We can use aspirated fat tissue as lipoinjection material but not excised fat tissue.
Aspirated fat is fragile parts of the adipose tissue taken with negative pressure. Our
research revealed that aspirated fat tissue contains only a half number of ASCs compared
to intact fat tissue [4] (Fig. 3). The two main reasons for this relative deficiency of ASCs
contained in aspirated fat tissue are 1) a major portion of ASCs are located around large
vessels (within tunica adventitia) and left in the donor tissue, and 2) a part of ASCs are
released into the fluid portion of liposuction aspirates [6]. Our histological study indicatedthat ASCs located not only between adipocytes but also around vessels. Large-sized
vessels are located in the fibrous part of the tissue, which intact fat tissue but not aspirated
fat tissue contains. Thus, aspirated fat tissue is regarded as relatively progenitor-poor fat
tissue compared to intact fat tissue [4].
3) Stromal vascular fraction (SVF)
Through collagenase digestion, heterogeneous cell mixture which contains anyother cell types than adipocytes can be extracted from adipose tissue as a cell pellet. The
cell fraction is called “stromal vascular fraction (SVF)” (Fig. 4), because they are basicallystromal cells and contain vascular endothelial and mural cells. In clinical setting, SVF
contains a substantial amount of blood-derived cells such as leucocytes and erythrocytes
as well as adipose-derived cells such as ASCs and vascular endothelial cells [6]. Our study
revealed that nucleate cells contained in SVF are composed of 37% of leucocytes, 35% ofASCs, 15% of endothelial cells and other cells, though the percentage of blood-derived
cells strongly depends on individual hemorrhage volume [7]. In CAL, the freshly isolated
autologous SVF is used as a supplementation for fat graft tissue without any
manipulations such as cell sorting or cell culture [3,5].

64) Concept of Cell-Assisted Lipotransfer (CAL)
Aspirated fat tissue has a significantly lower progenitor/mature-cell ratio as
mentioned above, and this low ASC/adipocyte ratio may be the main reason for long-term
atrophy of transplanted adipose tissue. There are at least three experimental studies
including ours [4,13,14], demonstrating that supplementation of adipose progenitor cells
enhances the volume or weight of surviving adipose tissue. Enrichment of adipose
progenitor cells by supplementation of SVF improves progenitor/adipocyte ratio;
progenitor-poor aspirated fat tissue will be converted to progenitor-rich fat tissue. In CAL,
freshly isolated SVF, which contains ASCs, is supplemented to progenitor-poor aspirated
fat tissue; the cells are attached to the aspirated fat with the fat acting as a living
bioscaffold before transplantation (Fig. 5).
Transplanted adipose tissue encounters ischemia and subsequent reperfusion as wellas high internal pressure by edema and inflammatory changes in the host tissue. The
microenvironments, injury-associated growth factors, and inflammation-associatedcytokines and chemokines would influence on ASC behaviors during the acute phase oftissue repair [15]. Adipose grafts undergo adipocyte and capillary remodeling, and ASCs
are a main cell population functioning in the repairing process of the adipose tissue [15].
The relative deficiency of ASCs in aspirated fat tissue may affect the replacement process
and lead to post-operative atrophy of grafted fat, which is known to commonly occur
during the first 6 months after lipoinjection.
V. Operative technique1) Surgical procedures
A) Basic breast augmentation
Donor sites are usually the thighs alone or the thighs and the abdomen or flanks,
decided according to patient’s preference and BMI. After the liposuction site is infiltrated
with saline solution with epinephrine (0.001%) under general anesthesia, adipose tissue issuctioned using a cannula with 2.5-mm inner diameter and a conventional liposuction
machine. The lipoaspirates are centrifuged at 700 g for 3 min, and put into a metal jar(1,000 ml) which is placed in water with crushed ice.
For the injection syringe, a 10 cc LeVeen™ inflator (Boston Scientific Corp., MA) or
our original syringe (20 ml) is used because they are screw-type syringes (with a threaded
plunger) and threaded connections that fit both the connecting tube and the needle, toallow for precise control during injection (Fig. 6). To reduce the time of the procedure,
two syringes are used; while one syringe is being used for an injection, the other is filledwith the graft material in preparation for the next injection. A 16 or 18-gauge needle (150mm long) is used for lipoinjection and inserted subcutaneously from inflamammary foldor areolar margin (Fig. 7). The operator takes care to insert and place the needle
horizontally (parallel to the body), in order to avoid damaging the pleura and causing apneumothorax. The needle is inserted in several layers and directions, and is continuously
and gradually retracted as the plunger is advanced (Fig. 7). This technique is used toobtain a diffuse distribution of the graft material. The grafts are placed into the fatty layers
on, around, and under the mammary glands (but not intentionally into the mammary
glands), and also into the pectoralis muscles. After training, it is not hard for an operator to7recognize the mammary gland or pectoralis fascia as a harder tissue than the fat or muscle
tissue. Injection is discontinued when the skin tension becomes tense; average volume of
injection is 250-300 ml for each breast.
B) Breast implant replacement
For patients with implants, lipoinjection can be performed simultaneously withimplant removal. Breast implants are removed through a periareolar incision, which isplaced at a caudal third of the areola margin. The lipoinjection is begun at the deepest
layer under the implant capsule and completed with the injection into the most superficial
subcutaneous layer. In the deepest layer, the operator takes care to insert and place theneedle horizontally (parallel to the body), in order to avoid damaging the pleura andcausing a pneumothorax, by inserting the operator’s finger into the implant capsule,placing it on the bottom of the capsule, and recognizing the location of the injection needle(Fig. 8). The needle is inserted from the lateral margin of the breast and from theinflamammary fold. Injection into the mammary glands or into the capsular cavity is not
performed. Finally, the capsular cavity is washed with saline and the periareolar incision isclosed.
C) Breast reconstruction
For breast reconstruction, lipoinjection is performed basically similar to basic breast
augmentation. Centrifuged lipoaspirates are injected from the inframammary fold or scars.
In cases who have substantial scar tissues or adhesion between skin and deep tissues,
tissue expander is inserted first and breast reconstruction with lipoinjection is performed
as a secondary surgery immediately after removal of the tissue expander. The volume of
injection is usually determined by skin tension of the reconstructed breast.
2) Preparation procedures of graft materialsA) Conventional lipoinjection
A needed volume of lipoaspirates is harvested by liposuction and centrifuged at 700
g for 3 min, and put into a metal jar (1,000 ml) which is placed in water with crushed ice.
As the centrifugation reduces the adipose volume by 25-30%, the volume reduction should
be taken into account in tissue harvesting.
B) Full-CAL
In full-CAL, about twice volume of lipoaspirates is harvested and a half of adipose
portion and all of fluid portion of liposuction aspirates are used for isolation of SVF (Fig.
1). If a patient has 25< of BMI, 1,500 ml of aspirated fat tissue can be easily harvested
from the abdomen and flanks or thighs. If BMI is less than 20, fat should be usually takenfrom both the abdomen and thighs.
About a half of the collected liposuction aspirate (500-700 ml of aspirated fat tissue)
is used for harvest of SVF. The SVF is isolated as described below and the cell processing
procedure takes about 80 min. During the processing period, the other half of lipoaspirates
is harvested and prepared as a graft material with centrifugation at 700g for 3 min. The
freshly isolated SVF was added to the centrifuged fat tissue, followed by gentle mixing
and a 10-15 min incubation to achieve appropriate cell adhesion to the centrifuged fat
tissue.
C) Mini-CAL

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In mini-CAL, the same volume of lipoaspirates is harvested as a conventional
lipoinjection; the adipose portion is centrifuged as graft materials, while the fluid portionof liposuction aspirates is used for isolation of SVF. The cell processing process takes
about 30 min. The freshly isolated SVF is added to the centrifuged fat tissue, followed bygentle mixing and a 10-15 min incubation to achieve appropriate cell adhesion to thecentrifuged fat tissue.
3) Cell isolation procedure (Cell processing for SVF isolation)
Processed lipoaspirate cells (PLA) cells and liposuction aspirate fluid (LAF) cells,
both are so-called SVF, are separated from the fatty and fluid portions of liposuction
aspirates, respectively. Both cells are used for full-CAL, while only LAF cells are used formini-CAL (Fig. 1).
For PLA cells, the suctioned fat is digested with 0.075% collagenase in phosphatebuffered saline for 30 min on a shaker at 37°C after centrifugation. Mature adipocytes andconnective tissues are separated from cell pellets by centrifugation (800g, 10 min). Pellets
were resuspended in erythrocyte lysis buffer (155 mM NH4Cl, 10 mM, KHCO3, 0.1 mM
EDTA) and incubated for 5 min at room temperature. The pellets are resuspended andpassed through a 100-mm mesh filter. To eliminate remaining collagenase, the cells pellets
are repeatedly washed with resuspending in Dulbecco's modified Eagle's medium(DMEM) and following centrifugation at least three times. For LAF cells, the suctioned
fluid is centrifuged (400g, 10 min), and the pellets are resuspended in erythrocyte lysis
buffer. After 5 min incubation at room temperature, lysates were passed through a 100mm mesh filter. The cell pellets are repeatedly washed with resuspending in DMEM andfollowing centrifugation at least three times, and passed through a 100-mm mesh filter.
The whole procedure should be performed by well-trained physicians or techniciansin an aseptic room (preferably at a level of good manufacturing practice) according to a
designated standard operating procedure. Isolated cells should be strictly evaluated inquantity and quality. Cell counts for erythrocytes and nucleated cells are performed using
a cell counter for blood test. The whole process of cell isolation takes about 80 minutes. It
is also recommended that a fraction of the isolated SVF is seeded and cultured to makesure of cell viability and another fraction is frozen and stored in a deep freezer or liquid
nitrogen for a future cell tracing.
VI. Pitfalls and how to correct

1) Pre- and post-operative evaluations
For evaluation of clinical results, physical measurements (maximum and bottom
breast circumferences, etc.), mammogram, MRI, echogram, photograph, and videographare performed. We also adopted a 3-dimensional measurement system which enables avolumetric evaluation of the breast mound in a standing position (Fig. 9). Echogram iseasy to perform at every patient’s visit and sensitive enough to detect small cyst formation.
Long follow up with annual mammogram is recommended to detect abnormal signs suchas calcification.
2) Clinical results

9Total operation period is approximately 2-2.5 hours for conventional lipoinjection,
2.5-3 hours for mini-CAL, and 3.5-4 hours for full-CAL. The time of the injection process
ranges from 35 to 60 min for both breasts. Subcutaneous bleeding and edema is usuallyseen on some parts of the breasts, and resolved in one to two weeks. Transplanted adipose
tissue is gradually absorbed during the first 2 postoperative months (especially during thefirst month), and the breast volume showed a minimal change thereafter, though skintension sometimes becomes looser between 2 and 6 months. The 3-dimensional
measurements showed that the surviving fat volume in full-CAL ranged from 100 to 250ml at 12 months, meaning that the graft take ranged from approximately 40% to 80% (Fig.
10). Compared to breast augmentation with implants of the same size, augmentation withlipoinjection showed a lower height but more natural contour of breasts. Cyst formation
depends on the volume and distribution of fat grafts. No cysts are palpable as far as
injection was appropriately performed (see below), though cysts with a size of less than
5mm may be detected by echogram. Patients are generally satisfied with the resulting
texture, softness, contour and absence of foreign materials despite the limited size increase
possible with autologous tissue. CT scans and MRI show that transplanted fat tissue
survives well and forms a significant thickness of the fatty layer not only subcutaneously
on and around the mammary glands but also between the mammary glands and thepectoralis muscles.
3) Refinement of autologous fat graft techniques
Surviving fat volume varies substantially among patients, and multiple factors arelikely to affect the clinical results; patient factors include skin redundancy of the breast
and technical factors include devices, graft fat preparation, and injection techniques. It is
well accepted that adipose tissue should be placed as small aliquots, preferably within anarea 3 mm in diameter. Since it takes a long time to perform ideally diffuse placement ofsuctioned fat in breasts [1], we use a disposable syringe with a threaded plunger andconnections and a very long needle (150 mm); these devices are critical to performing
large-volume lipoinjection safely and precisely in a short time [3] (Fig. 6). We use a
relatively large-sized suction cannula (2.5-3.5 mm of inner diameter), centrifuge theaspirated fat, and keep it cooled until transplantation. It should be also noted that aspirated
fat tissue should be injected as soon as possible, such as within 60 min after harvest. In our
experience, clinical results (increase in breast size) appeared to be superior whencentrifuged fat was used compared to non-centrifuged fat. This may be due to theimproved adipocyte density and ASC/adipocytes ratio after centrifugation [16]. ASC
supplementation dramatically improves ASC/adipocyte ratio and is suggested to minimize
adipose atrophy after transplantation, though further studies are needed to elucidate theeffects of ASCs.
4) Complications
If injection was performed inappropriately, problems derived from fat necrosis
would be seen such as no augmentation effects, cyst formation, fibrogenesis, andcalcification. Small cysts (< 8 mm) detected by echogram usually disappear between 9 and18 months, so no treatment is needed. Tiny calcifications may occur 1-2 years after
surgery but they are very rare and easy to distinguish from malignant signs. To record

10them as mammogram is important and useful to distinguish from abnormal changes in the
future. A larger volume of liposuction could induce postoperative donor site problems
such as irregularity or seroma, which are more susceptible in lean patients, so thatpreoperative selection of patients and careful procedures in liposuction are desirable.
5) Representative cases
Representative cases were demonstrated in Figures 11-15; one case from eachcategory (breast augmentation with conventional lipoinjection, breast augmentation withfull-CAL, breast implant replacement with full-CAL, inborn breast deformity treated withfull-CAL and breast reconstruction with full-CAL).

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VII. Post-operative care
After the surgery, the breasts should be kept in a proper position with a proper-sized
brassier. Patients can take a shower on the next day. Massage of the breasts is prohibited
during the first 3 months.
VIII. Conclusions
Increase in size obtained by lipoinjection is moderate, but patients can achieve softand natural-looking breasts without any future concerns associated with foreign body.
Major complications are not seen as far as the infiltration technique is appropriate. Our
preliminary experiences of CAL technique suggested the efficacy and safety of the ASC
supplementation. Through further improvements of the technique and longer follow-up
studies, autologous tissue transfer may become widely used for augmentation andreconstruction of the breasts in the future.

12References
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2. Tuli R, Flynn RA, Brill KL, Sabol JL, Usuki KY, Rosenberg AL. (2006) Diagnosis,
treatment, and management of breast cancer in previously augmented women. Breast J 12:
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lipotransfer (CAL) for cosmetic breast augmentation -supportive use of adipose-derived
stem/stromal cells-. Aesthetic Plast Surg 32: 48-55
4. Matsumoto D, Sato K, Gonda K, Takaki Y, Shigeura T, Sato T, Aiba-Kojima E, Iizuka
F, Inoue K, Suga H, Yoshimura K (2006) Cell-assisted lipotransfer: supportive use ofhuman adipose-derived cells for soft tissue augmentation with lipoinjection. Tissue Eng
12: 3375-3382
5. Yoshimura K, Sato K, Aoi N, Kurita M, Inoue K, Suga H, Eto H, Kato H, Hirohi T,
Harii K (2008) Cell-assisted lipotransfer for facial lipoatrophy: efficacy of clinical use of
adipose-derived stem cells. Dermatol Surg 34: 1178-1185
6. Yoshimura K, Shigeura T, Matsumoto D, Sato T, Takaki Y, Aiba-Kojima E, Sato K,
Inoue K, Nagase T, Koshima I, Gonda K (2006) Characterization of freshly isolated andcultured cells derived from the fatty and fluid portions of liposuction aspirates. J Cell
Physiol 208: 64-76
7. Suga H, Matsumoto D, Inoue K, Shigeura T, Eto H, Aoi N, Kato H, Abe H, Yoshimura
K (2008) Numerical measurement of viable and non-viable adipocytes and other cellularcomponents in aspirated fat tissue. Plast Reconstr Surg 122: 103-114
8. Zuk PA, Zhu M, Ashjian P, De Ugarte DA, Huang JI, Mizuno H, Alfonso ZC, Fraser
JK, Benhaim P, Hedrick MH (2002) Human adipose tissue is a source of multipotent stem
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triglyceride turnover, de novo lipogenesis, and cell proliferation in humans measured with
2H2O. Am J Physiol Endocrinol Metab 286: E577-E5888
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11. Garcia-Olmo D, Garcia-Arranz M, Herreros D, Pascual I, Peiro C, Rodriguez-Montes
JA (2005) A phase I clinical trial of the treatment of Crohn’s fistula by adipose
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13. Masuda T, Furue M, Matsuda T (2004) Novel strategy for soft tissue augmentation
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Legends

Fig. 1 Scheme of conventional lipoinjection and cell-assisted lipotransfer (CAL). The
adipose portion (yellow) of liposuction aspirates is centrifuged and used as injection
materials in conventional lipoinjection. In mini-CAL, the fluid portion (pink) of
liposuction aspirates is used for isolation of stromal vascular fraction (SVF) containing
adipose progenitor cells. In full-CAL, another volume of liposuction aspirates isadditionally harvested for SVF isolation. Freshly isolated SVFs are used forsupplementation of adipose progenitor cells to grafting tissues. (For the supplementationof SVF, see also Fig. 5)

15

Fig. 2 Scheme of adipose tissue components. Adipocytes constitute more than 90% of
tissue volume, but only less than 50% of cells in number. Adipose-derived stromal/stem
cells (ASCs), endothelial cells, fibroblasts, and other cells constitute the rest of cellcomponents. Extracellular matrix (ECM) of the adipose tissue contains some types ofcollagens, laminin, fibrinogen and others.

16

Fig. 3 Comparison of human intact fat tissue and aspirated fat tissue obtained from asingle site of a single patient. Schematic views (top), electromicroscopic and whole mountstaining images (middle), and isolated progenitor cells (bottom). The basic structure of
adipose tissue was preserved in the aspirated fat, while vascular vessels, especially thoseof large size, were significantly less detected in aspirated fat compared to the excised fat.
It is well known that the honeycomb structures of vascular and neural perforator networks
are left intact in aspirated sites after liposuction operation. ASC yield from aspirated fat
tissue was significantly less (56 ± 12 %) than that from excised fat tissue.

17Fig. 4 Stromal vascular fraction (SVF) can be obtained from adipose and fluid portions ofliposuction aspirates through collagenase digestion. SVF contains 10-40% of adiposederived stromal cells (ASCs) (CD34+CD31-CD45-), part of which have multipotency andcan differentiate experimentally into several lineages in vitro. SVF contains also bloodderived cells (CD45+ cells) such as leukocytes. ASCs are considered to physiologicallydifferentiate into adipocyte and vessels.

18

Fig. 5 Concept of cell-assisted lipotransfer (CAL). Relatively progenitor-poor aspirated fat
tissue is converted to progenitor-rich fat tissue by supplementation with the stromal
vascular fraction (SVF) isolated from one-half of the aspirated fat sample (Strictly
speaking, the source of SVF differs between mini-CAL and full-CAL; see also Fig. 1 forthe difference). SVF cells are attached to the aspirated fat tissue, which acts a scaffold inthis strategy.

Fig. 6. Injection devices. A high-pressure injection can be performed with a disposable
syringe with a threaded plunger. A 150 mm-long 16- or 18-gauge needle is connected tothe syringe with a connecting tube threaded at both ends. The injection needle is rigidly
manipulated by an operator, while an assistant rotates the plunger according to theoperator’s instruction.

19

Fig. 7. Schematic instruction of the injection method. (top) The needle is inserted fromeither the areola margin or the infra-mammary fold in variable directions and planes toachieve a diffuse distribution. A small amount of fat tissue is injected as small aliquots ora thin string with a long needle on a syringe with a threaded plunger while the needle iscontinuously withdrawn. (bottom) Approximately 200-300 ml of fat tissues is usually
injected for cosmetic breast augmentation on each side. Fat is not injected into themammary glands, but into any other layers including the pectoralis muscles.

Fig. 8 Schematic illustration of the lipoinjection procedure for breast implant replacement.
While injecting, operator’s fingers are inserted through a periareolar skin incision into thecavity of implant capsule to determine the location of the needle tip.

20

Fig. 9 Three-dimensional measurement system for breast volume. Breast volume at asitting position can be measured by this system. Perpendicular striped lights are shown on
the breasts and photographed with a stereo-type digital camera. The digital images arethen analyzed with a customized software; the volume and projection of each breast above
a standard plane designated by three fixed points (the shoulder, suprasternal notch, andxiphoid process) which do not usually shift after breast augmentation, are calculated.

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Fig. 10 Sequential volume changes after full-CAL measure by the three-dimensional
measurement system (Preliminary results of 28 patients). Augmented volume variedamong patients from 100 to 250 ml at 6 months, which corresponds to 40-90% survival oftransplanted adipose tissue.

Fig. 11 Case 1 (Breast augmentation with conventional lipoinjection): Preoperative view(left) and postoperative views at 6 months (right). A 36-year-old woman underwent breast
augmentation with conventional lipoinjection (280 ml in each breast). The breast mounds
were soft and natural with no subcutaneous indurations, though the augmentation effectwas moderate.

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Fig. 12 Case 2 (Breast augmentation with full-CAL): A 30-year-old woman underwent
breast augmentation with CAL (310 ml in each breast). Preoperative views (top) andpostoperative views at 24 months (bottom). Her breasts were dramatically augmented withan increase in breast circumference difference by 8.0 cm at 24 months. The breast mounds
were soft with no subcutaneous indurations. An original infra-mammary fold on the left
breast is slightly visible, but injection scars are not visible. Mammograms 24 months after
surgery show no abnormal signs.

Fig. 13 Case 3 (Breast implant replacement with full-CAL): A 33-year-old woman who
had 210 ml saline implants underwent implant removal and simultaneous CAL (260 ml ineach breast). Preoperative (left panels) and postoperative (right panels) views at 12 months.

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Clinical views showed capsular contracture and upward displacement of the left implant
before surgery (top, left), while the breasts had a natural and symmetrical appearance at 12
months (top, right). T1-weighted MRI (middle, left, and right) revealed that thetransplanted adipose tissue survived and formed thick layers around and under the
mammary gland at 12 months. Mammograms showed that neither implant was ruptured
before surgery (bottom, left) and that no calcification or other abnormal signs were visiblein either breast at 12 months (bottom, right). Augmented breast mounds maintained
sufficient breast volume even after implant removal, and were naturally soft without any
subcutaneous indurations.

Fig. 14 Case 4 (Inborn deformity treated with full-CAL): A 26-year-old woman, who hada hypoplastic breast along with thoracic deformity on the right side, underwent CAL
augmentation for both sides (325 ml and 105 ml on the right and left, respectively)
Preoperative (left panels) and postoperative (right panels) views at 12 months. Bothbreasts were significantly improved without any indurations detected. A few small
injection scars on the inframammary folds are left, but nearly invisible. Pre- and postoperative CT scans (bottom, left and right) show that adipose tissues were augmented not
only subcutaneously but also under the mammary glands with no abnormal nodules or
calcifications detected.

24Fig. 15 Case 5 (Breast reconstruction after mastectomy with full-CAL): A 43-year-old
woman, who had undergone partial mastectomy followed by irradiation therapy,
underwent breast reconstruction with full-CAL (240 ml on the left side). The right healthyside was also augmented by full-CAL of 160 ml. Preoperative (left) and postoperative(right) views at 12 months. Both breasts were augmented very well, and the reconstructedbreast mound was soft and showed natural skin texture.