Aesth Plast Surg (2008) 32:48–55
DOI 10.1007/s00266-007-9019-4

ORIGINAL ARTICLE

Cell-Assisted Lipotransfer for Cosmetic Breast Augmentation:
Supportive Use of Adipose-Derived Stem/Stromal Cells
Kotaro Yoshimura Æ Katsujiro Sato Æ Noriyuki Aoi Æ Masakazu Kurita Æ
Toshitsugu Hirohi Æ Kiyonori Harii

Received: 27 April 2007 / Accepted: 22 May 2007 / Published online: 1 September 2007
Ó Springer Science+Business Media, LLC 2007

Abstract
Background Lipoinjection is a promising treatment but
has some problems, such as unpredictability and a low rateof graft survival due to partial necrosis.
Methods To overcome the problems with lipoinjection,
the authors developed a novel strategy known as cellassisted lipotransfer (CAL). In CAL, autologous adiposederived stem (stromal) cells (ASCs) are used in combination with lipoinjection. A stromal vascular fraction (SVF)
containing ASCs is freshly isolated from half of the aspirated fat and recombined with the other half. This process
converts relatively ASC-poor aspirated fat to ASC-rich fat.
This report presents the findings for 40 patients who
underwent CAL for cosmetic breast augmentation.

Partially presented at the 3rd annual meeting of the International Fat
Applied Technology Society (IFATS), Charlottesville, Virginia, 11
September 2005, and the 8th annual meeting of Tissue Engineering
Society International (TESI), Shanghai, China, 23 October 2005.
K. Yoshimura (&)  N. Aoi
Department of Plastic Surgery, University of Tokyo School of
Medicine, 7-3-1 Hongo, Bunkyo-ku, 113-8655 Tokyo, Japane-mail: yoshimura-pla@h.u-tokyo.ac.jp
K. SatoCellport Clinic Yokohama, Yokohama Excellent III Building 2F,
3-35, Minami-nakadori, Naka-ku, Yokohama, 231-0006
Kanagawa, Japan
M. Kurita  K. Harii
Department of Plastic Surgery, Kyorin University School of
Medicine, 6-20-2 Shinkawa, Mitaka-shi, 181-8611 Tokyo, Japan
T. Hirohi
Ritz Cosmetic Surgery Clinic Tokyo, Meguro Toho Building 8F,
3-1-7, Kamiosaki, Shinagawa-ku, 141-0021 Tokyo, Japan

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Results Final breast volume showed augmentation by 100
to 200 ml after a mean fat amount of 270 ml was injected.
Postoperative atrophy of injected fat was minimal and did
not change substantially after 2 months. Cyst formation or
microcalcification was detected in four patients. Almost all
the patients were satisfied with the soft and naturalappearing augmentation.
Conclusions The preliminary results suggest that CAL iseffective and safe for soft tissue augmentation and superior
to conventional lipoinjection. Additional study is necessary
to evaluate the efficacy of this technique further.
Keywords Adipose-derived stem/stromal cells Breast augmentation  Cell therapy  Lipoinjection 
Tissue engineering

Autologous fat transplantation is one promising treatment
for facial rejuvenation and soft tissue augmentation
because it results in no incisional scar or complications
associated with foreign materials. However, certain problems remain, such as unpredictability and a low rate ofgraft survival due to partial necrosis. Many innovations to
overcome these problems have been reported [1, 2, 4–6,
18] and reviewed previously [4, 14]. On the basis of thesereports, we tentatively concluded that we could harvest fat
with a 2.5-mm cannula or 18-gauge needle at a vacuum
lower than 700 mmHg and reinject it using an 18-gauge
needle without significant adipocyte damage [14].
Lipoinjection can be used to treat facial changes associated with aging and to correct various types of depressed
deformities such as hemifacial microsomia and pectus excavatum. It also has been used in breast augmentation by alimited number of plastic surgeons [3], although the useof autologous fat for breast augmentation has been

Aesth Plast Surg (2008) 32:48–55

controversial. Consensus is lacking on whether lipoinjection is safe and appropriate because of microcalcifications
that may cause confusion in the evaluation of mammograms. Recently, autologous fat injection has beenreevaluated as a potential alternative to artificial implants
for breast augmentation [3, 15, 16, 19]. This reevaluation
may reflect recent advances in autologous fat transfer andthe radiologic detection of breast cancer.
To overcome the problems associated with autologous
fat transfer, we use a novel strategy known as cell-assisted
lipotransfer (CAL) (Fig. 1). Findings have shown that tissue-specific progenitor cells in the adipose tissue have thecapacity to differentiate into various cell lineages [21].
Thus, the progenitors, currently known as adipose-derived
stem/stromal cells (ASCs), are expected to become avaluable tool in a wide range of cell-based therapies.
The therapeutic concept of CAL was described in ourprevious report on preclinical studies [9]. We found that
aspirated fat has approximately half the number of ASCs
found in excised whole fat. There are two main reasons forthis relative deficiency. First, a major portion of the ASCs
is located around large vessels and left in the donor site
after liposuction [9]. Second, a part of the ASCs is released
into the fluid portion of liposuction aspirates [20]. The
relative deficiency of ASCs may induce postoperative
long-term atrophy of injected fat, as partially confirmed inanimal studies [8, 9, 11].
With the CAL strategy, autologous ASCs are used toenhance angiogenesis, to improve the survival rate ofgrafts, and to reduce postoperative atrophy. In CAL, half
the volume of the aspirated fat is processed for isolation of
the stromal vascular fraction (SVF) containing ASCs.
During the isolation process, the other half of the aspirated
fat is prepared for grafting. Freshly isolated SVF, which we

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characterized previously [20], is attached to the aspirated
fat, with the fat acting as a living scaffold before transplantation. Finally, the SVF-supplemented fat is injected
into the target sites. Thus, ASC-poor fat is converted toASC-rich fat in the preparation process of the injectablematerial.
In this report, we describe the preliminary results
experienced by patients who underwent CAL for cosmeticbreast augmentation. This is the first report on the clinicaluse of ASCs for cosmetic purposes.

Materials and Methods
Patients
From 2003 to 2007, we performed CAL for 70 patients: inthe breast for 60 patients (including 8 patients who hadbreast reconstruction after mastectomy), in the face for 12
patients, and in the hip for 1 patient. For three patients,
CAL was performed at two sites. Informed consent was
obtained from all the patients. The study protocol conformed to the guidelines of the 1975 Declaration of
Helsinki and was approved by individual institutional
review boards.
In this study, 40 patients with healthy thoraxes andbreasts underwent CAL for purely cosmetic breast augmentation. Patients undergoing breast reconstruction forinborn anomaly or after mastectomy were not included. At
this writing, 19 of these 40 patients have been followed formore than 6 months, and the maximum follow-up period
has been 42 months. All the patients were Japanese womenwith a mean body mass index (BMI) of 19.1  1.9. Theirages varied from 20 to 62 years (mean, 35.8  9.1). The

Fig. 1 Scheme of cell-assisted
lipotransfer. Relatively adiposederived stem/stromal cell(ASC)-poor aspirated fat isconverted to ASC-rich fat by
supplementing ASCs isolated
from the other half of theaspirated fat. The ASCs areattached to the aspirated fat,which is used as a scaffold inthis strategy

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Aesth Plast Surg (2008) 32:48–55

mean volume of injected fat was 268.1  47.6 ml on theleft side and 277.3  39.1 ml on the right side. The
demographic and surgical data for these patients are summarized in Table 1.

60 ml of saline, then diffusely injected into the wholebreast mounds separately (30 ml for each breast) immediately after conventional lipoinjection. There were 6
patients in group A, 2 patients in group B, and 32 patientsin group C.
For the injection syringe, a 10-ml LeVeen inflator(Boston Scientific Corp., Boston, MA, USA) or our original 20-ml syringe was used because each is a screw-typesyringe (with a threaded plunger), and the threaded connections fit both the connecting tube and the needle toallow precise control during injection. To reduce the timeof the procedure, two syringes were used. While the one
syringe was being used for an injection, the other was being
filled with the graft material in preparation for the next
injection. An 18-gauge needle (150 mm long) was used forlipoinjection and inserted subcutaneously at one of four
points indicated in Figs. 2A and B.
The operator took care to insert and place the needle
horizontally (parallel to the body) to avoid damaging thepleura and causing a pneumothorax. The needle wasinserted in several layers and directions. It was continuously and gradually retracted as the plunger was advanced.
This technique was used to obtain a diffuse distribution of
the graft material (Figs. 2 and 3). The grafts were injected
into the fatty layers on, around, and under the mammary
glands, and also into the pectoralis muscles.

Surgical Techniques

Results

Before the procedure began, the liposuction site was
infiltrated with combined saline solution and diluted epinephrine (0.001%). With the patient under generalanesthesia, adipose tissue was suctioned using a cannulawith a 2.5-mm inner diameter and a conventional liposuction machine. Approximately half of the collected
liposuction aspirate was used for isolation of the SVF fromboth the adipose and fluid portions of the liposuction
aspirates, as described previously [20]. This cell processing
procedure required about 90 min. During the processing
period, the other half of the lipoaspirate was harvested asgraft material.
The adipose portion of the liposuction aspirates waseither washed several times and placed in an uprightposition to obtain clear separation of fluids and oil (groups
A and B) or centrifuged at 700 g for 3 min without washing(group C), then put into a metal jar (500 ml), which wasplaced in water with crushed ice. In groups A and C, thefresh SVF isolated from both the adipose and fluid portions
was added to the graft material. After gentle mixing and a
wait of 10 to 15 min for cell adherence to the aspirated fat,the cell-supplemented fat was put into an injection syringe.
In Group B, the freshly isolated SVF was resuspended in

The transplantation of adipose tissue was successfully
performed in all cases, and the time of the injection process
ranged from 35 to 60 min for both breasts. Subcutaneous
bleeding, occasionally seen in some parts of the breasts,
resolved in 1 to 2 weeks.
Transplanted adipose tissue was gradually absorbed
during the first 2 postoperative months (especially during
the first month), and the breast volume showed a minimalchange thereafter, although skin tension sometimes lessened after 2 months. Three representative surgical sites areshown in Figs. 4 to 9. The difference in breast circumference (chest circumference at the nipple minus the chest
circumference at the inframammary fold) had increased in
all cases by 4 to 8 cm at 6 months, which corresponds to
two to three brassiere cup sizes. This circumference
increase appeared to correspond to the 100- to 200-ml
increase in the volume of each breast mound, which waspartially confirmed by our preliminary evaluation using athree-dimensional quantitative measurement system.
Compared with breast augmentation using implants ofthe same size, augmentation with CAL showed a lower
height but a more natural contour of the breasts. All cases
but one (see later) showed natural softness of the breasts

Table 1 Patient data
No. of cases

40

Sex

40 F, 0 M

Age (years)

35.8  9.1

BMI

19.7  1.9

Surgical procedure
Group A

6

Group B

2

Group C

32

Site of liposuction
Thighs25

Thighs and abdomen

13

Thighs and lower legs
Total volume of suctioned fat (ml)21111.8  164.0

Volume of injection (ml)Left

268.1  47.6

Right

277.3  39.1

Operation time (min)257.1  39.1

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detected by mammogram in two patients at 24 months. In
one of two patients in group B, fibrous breast tissue andfibrosis on the sternum were observed by computed
tomography (CT) scan at 6 months, and the breasts were
found to be harder than in other cases.

Discussion

Fig. 2 Schematic instruction of the injection method. (A) A small
amount of fat tissue is injected as small aliquots or as a thin stringwith a long needle, using a syringe with a threaded plunger, while theneedle is continuously withdrawn. (B) The needle is inserted fromeither one of two points on the areola margin or one of two points at
the inframammary fold in variable directions and planes to achieve a
diffuse distribution

Fig. 3 A clinical view of injection. The injection needle is rigidly
manipulated by an operator while an assistant rotates the plunger
according to the operator’s instruction. A high-pressure injection canbe performed using a disposable syringe with a threaded plunger. A
150-mm-long, 18-gauge needle is connected to the syringe with aconnecting tube threaded at both ends

without any palpable nodules at 6 months, and all thepatients were satisfied with the resulting texture, softness,
contour, and absence of foreign materials despite the limited size increase possible with autologous tissue—Cyst
formation (\12 mm) was detected by magnetic resonanceimaging (MRI) in two patients, and microcalcification was

Modifications of lipoinjection techniques to improve thesurvival rate for injected fat have been attempted. Fromthese, it is well accepted that adipose tissue should beplaced as small aliquots [3], preferably within an area 3
mm in diameter [1]. Because it takes a long time to perform
ideally diffuse distribution of suctioned fat [3], we haveused a disposable syringe with a threaded plunger andconnections, a very long needle (150 mm), and an assistantto rotate the plunger. As a result, only 35 to 60 min are
required for injection in both breasts. These devices are
critical to performing large-volume lipoinjection safely andprecisely in a short time.
In addition, the harvesting, preserving, and refining ofgraft materials also are important, as repeatedly indicatedin the literature. We used a relatively large suction cannula,centrifuged the aspirated fat in some cases, and kept itcooled until transplantation. In this study, the clinicalresults (increase in breast circumference) appeared to bebetter in group C (using centrifuged fat) than in group A(using noncentrifuged fat), although quantitative measurement and statistical comparison were not done. In aprevious study, we found that centrifugation of aspirated
fat is substantially influential because centrifugation at
1,200 g decreases the fat volume by 30%, damaging 12%of the adipocytes and 0% of the ASCs. This leads to theconcentration of cell numbers per volume of adipocytes
and ASCs by 25% and 43%, respectively [7].
In addition, centrifugation may be especially beneficial
in our treatment because water content in the graft material
may disturb the adherence of ASCs to the adipose tissue
and interfere with differentiation into expected lineages.
Any ASCs floating in a solution, which is a nonphysiologic
environment, may migrate over distances, penetrate into
the lymphatic flow, and differentiate unexpectedly. We
believe that such migration and altered cell differentiation
caused the development of fibrotic tissue on the sternum of
one patient in group B. Thus, we conclude that centrifuged
fat combined with ASCs as cell pellets (group C procedure)
was best among the three methods used in this study.
Although small cystic formation and microcalcification
were detected in some cases, the microcalcification was
easily distinguished from that associated with breast cancer, and the overall cosmetic results were generally
satisfactory and encouraging. Almost all the patients were

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Aesth Plast Surg (2008) 32:48–55

Fig. 4 Clinical views of apatient in group A (patient 1).
Preoperative (left) andpostoperative (right) views at 24
months. A 22-year-old woman
underwent breast augmentation
using cell-assisted lipotransfer(CAL) (290 ml in each breast),with satisfactory results at 24
months. Her breast
circumference increased by 5
cm, and her augmented breast
mounds remained soft andnatural appearing without
injection scars or subcutaneous
indurations

Fig. 5 Radiologic views
showing the chest of patient 1.
(A) A preoperative computed
tomography (CT) image in thehorizontal plane of the nipples.
(B) A horizontal image 12months after surgery. Note thatthe adipose tissue is augmented
both subcutaneously and underthe mammary glands. (C)Mammograms at 12 months
show no calcification or otherabnormal signs

satisfied with their enlarged and soft breasts with a naturalcontour. Both CT scans and MRI showed that transplanted
fat tissue survived and formed a significant thickness of thefatty layer not only subcutaneously on and around the
mammary glands, but also between the mammary glands

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and the pectoralis muscles. Breast volume stabilized 2 to 3
months after transplantation.
Maximum breast augmentation using the described
technique varied among the patients and appeared to be
100 to 200 ml. Although these volumes may be smallerAesth Plast Surg (2008) 32:48–55

53

Fig. 6 Clinical views of apatient in group C (patient 2).
Preoperative (top) andpostoperative (bottom) views at
12 months. A 32-year-old
woman underwent breast
augmentation with cell-assisted
lipotransfer (CAL) (280 ml ineach breast). Her breast
circumference difference
increased from 9 cm (baseline)
to 14.5 cm (at 12 months). The
breast mounds are soft andnatural appearing with novisible injection scars

Fig. 7 Radiologic views
showing the chest of patient 2.
(A) A preoperative computed
tomography (CT) image in thehorizontal plane at the level ofthe nipples. (B and C)
Horizontal images by magnetic
resonance imaging (MRI) 12
months after surgery: (B) T1image; (C) T2-image. The
adipose tissue is augmented
around and under the mammary
glands. A small cyst (\10 mm)
appears in the fatty layer under
the right mammary gland. (D)Mammograms at 12 months
show no abnormal signs such as
calcifications

than those achieved with large artificial implants, a definite
advantage is that patients need not be concerned about
postoperative complications induced by artificial implants
such as rupture, infection, capsular contracture, unnaturalcontour, hardness, neurologic symptoms, and immune
response. Compared with our dozens of patients who
underwent conventional autologous lipoinjection to thebreasts, augmentation effects were apparently higher with

CAL. A 2- to 3-cm increase in breast circumference wascommon with the conventional procedure, compared withthe 4- to 8-cm increase seen in this trial of CAL, although
the augmentation effect varied among patients. The measurement system we recently devised may help to quantify
the difference in augmented volume in the future.
Adipose tissue contains not only adipogenic progenitor
cells, but also multipotent stem cells, which can

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Aesth Plast Surg (2008) 32:48–55

Fig. 8 Clinical views of apatient in group C (patient 3).
Preoperative (top) andpostoperative (bottom) views at
24 months. A 30-year-old
woman underwent breast
augmentation with cell-assisted
lipotransfer (CAL) (310 ml ineach breast). Her breasts weredramatically augmented with anincrease in breast circumference
difference by 8 cm at 24
months. The breast mounds
were soft with no subcutaneous
indurations. An original
inframammary fold on the left
breast is slightly visible, but
injection scars are not visible

Fig. 9 Radiologic views ofpatient 3. (A) A preoperative
computed tomography (CT)image in the horizontal plane at
the level of the nipples. Only avery thin fatty layer is observed
around the mammary glands.
(B) A horizontal magnetic
resonance image (MRI) (T1weighted) 24 months after
surgery. Transplanted adipose
tissues survived and formed
thick layers around and underthe mammary glands. (C)Mammograms 24 months after
surgery show no abnormal signs

differentiate into fat, bone, cartilage, and types of tissue[21, 22]. Suctioned fat appears to lose a significant
number of these precursors during liposuction and the
preparation processes as compared with nonsuctioned
adipose tissue [9]. This relative deficiency of precursors
may contribute to the low survival rate and long-term
atrophy of transplanted lipoaspirates. In CAL, the deficitof ASCs was compensated by supplementing ASCs. To
maximize the biologic function and avoid unexpectedbehavior of ASCs, it seems important to ensure adherence of supplemented ASCs to adipocytes or connective
tissue.
With this novel treatment, ASCs have four possibleroles, which were partly confirmed in preclinical studies [8,9, 11]. First, ASCs can differentiate into adipocytes andcontribute to the regeneration of adipose tissue. Second,
ASCs can differentiate into endothelial cells and also

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probably into vascular mural cells [8, 10, 12], resulting in
the promotion of angiogenesis and graft survival. Third,
ASCs are known to release angiogenic growth factors in
response to hypoxia and other conditions [13], and thesefactors influence surrounding host tissue. In their final role,
which may be the most influential, ASCs survive as original ASCs [9]. In the adipose tissue, ASCs reside between
adipocytes or in the extracellular matrix, especially aroundvessels, and contribute to the turnover of adipose tissue,
which is known to be very slow (2 years or more) [17].
However, adipose grafts probably turn over during the first
2 to 3 months after transplantation because they experience
temporary ischemia followed by reperfusion injury. This
turnover, the replacement process of the adipose tissue, isconducted by tissue-specific progenitor cells, which are
ASCs. The relative deficiency of ASCs in aspirated fat may
affect the replacement process and lead to postoperative

Aesth Plast Surg (2008) 32:48–55

atrophy of grafted fat, which is known to occur commonly
during the first 6 months after lipoinjection.
The freshly isolated SVF used in CAL contains not only
ASCs but also vascular endothelial cells, pericytes, blood
cells (both white and red), and other cells, as previously
described [20]. After transplantation, ASCs may interact
with other cells such as vascular endothelial cells, andsupplementation with the SVF may be superior to supplementation with ASCs alone in this treatment. However,further studies are needed to elucidate the synergistic
effects of ASCs with other cells contained in the graft.
In this preliminary study, satisfactory clinical results
were generally achieved without any major complications.
Thus, we can conclude that CAL is sufficiently safe forcontinuation of the study, though controlled investigations
and accumulated long-term results are needed to elucidate
the overall safety and efficacy of the treatment. A variety of
new innovations, including stem cell technology, may be
developed and may contribute to the improvement ofautologous tissue transplantation and regeneration. Further
improvements of the technique may cause autologous tissue transfer to become the first choice for breast
augmentation in the future.
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