INTRODUCTION
Over the last several decades, silicone gel or saline implants have been the most commonly used form of breast augmentation. However, their use is associated with complications. The capsule contraction rate varies from 4% for the technologically advanced implants to 60% for the smooth silicone implants/1) The reoperation rate is 20%/2) To reduce these problems, the transfer of adipose tissue was proposed. Several physicians have developed techniques for this tissue transfer/3"8)
To stabilize these fat transfers we have incubated the tissue in platelet-rich plasma (PRP). Autologous platelet gels have been used since 1982 to accelerate wound healing/9-11) The conversion of fibrinogen to fibrin produces a clot that facilitates hemostasis and closes dead space/12) The activation of platelet growth factors stimulates wound healing^13) by inducing
a chemotactic response for fibroblasts and an-gioblasts/14) We present our results and guidelines to facilitate this retention.
METHOD
The breasts of 65 female patients were augmented with "gelled" autologous adipose tissue enmeshed in a fibrin clot of PRP. They were examined over a 10-year period with photography, volumetric measurements, mammograms, and tissue biopsies.
Patient selection
An examination was completed to determine if the patient was a candidate for the procedure. Women in good health who had no personal history of breast malignancy, sufficient areas of dysharmonious obesity, and no severe breast ptosis were chosen. We preferred patients with the violin-type of fat deformity/15) Candidates were also chosen who were realistic and would be content with a one cup-size increase in volume. In addition to blood work (complete blood count, chemical profile, test for human
immunovirus, and hepatitis B and C screen) a history and physical examination, photography, a high-resolution mammogram, and volumetric measurements of each breast were completed on each patient
Informed consent
The risks and benefits of the procedure and of alternatives such as saline or silicone implants were explained to each patient. The possibilities of loss of breast volume, breast calcification, and the masking of future malignancy were discussed with each patient. The patients were told not to diet immediately before or after the procedure and that they might either lose or gain breast volume following recovery from the procedure.
They were told to inform their radiologist or surgeon reading their future mammograms that they had undergone breast surgery. They understood that this explanation would help explain any benign lipid cysts or benign "eggshell" calcifications to their physician and reduce the need for exploratory surgery.
Technique for preparation of platelet gel
Whole blood (400-500 cc) was collected from the patient with a dedicated peripheral intravenous catheter. The isolation of PRP was accomplished using the Medtronic AT500 gradient density cell separator. The blood specimen was collected into a standard labeled blood collection bag containing citrate phosphate dextrose anticoagulant. The blood was initially centrifuged at 5600 rpm to separate the platelet-poor plasma (PPP). Then, the blood was recentrifuged at 2400 rpm to separate further the PRP from the red blood cell pack. The PRP was aspirated into a 60 cc syringe and held at room temperature until the fat was ready for supplementation.
Adipose tissue collection
The night before and the morning of surgery the patient completed a total body scrub with chlorhexadine (Hibiclens). Before surgery^15) the areas of the body were marked for liposuction (Fig. 2) and lipoinjection (Fig. 3). The current breast volumetric measurement was written on each breast so that the augmentation volumes could be adjusted. A combination of propofol and ketamine was used to achieve dissociative anesthesia^16) while tumescent fluid was infiltrated into the areas of liposuction/17) Usually the thighs and flanks were infiltrated using a 30 cm blunt 2 mm stainless steel, multiple-port injection cannula. After a 20 min pause to allow for vasoconstriction, the Tulip-syringe technique was used for fat harvesting/18) A partial vacuum was produced by gradually withdrawing the plunger on a 60 cc
syringe that had been previously vented with 3 cc air. The initial 500-600 cc adipose tissue was collected with the syringe vacuum using a 30 cc blunt 3.7 mm liposuction cannula with a Mercedes tip (KMI, Anaheim, California). The same procedure was repeated on the opposite thigh and flank until 1000-1200 cc supernatant fat was obtained. Any final liposculpting was completed using conventional liposuction techniques.
The syringe aspirate was collected into a sterile glass container and washed two or three times with lactated Ringers solution to remove any broken fat cells or red blood cells. At this point the PRP was added. The mixture was stirred and allowed to "incubate" for 15 min. The resulting fibrin clot condensed the fatty layer and released water and debris so that only 50% of the supernatant fat remained for lipoinjection. The free water and free oil were discarded through a sieve (Fig. 4). The remaining PRP-adipose tissue was transferred to injection guns. The ratcheted syringe was set to deliver 1 cc aliquots through a triple-port blunt tip Lipoject needle (KMI, Anaheim, California) (Fig. 5). A total of 200-300 cc PRP adipose tissue was injected into each breast through a 2 mm stab incision below the inframammory fold. Small (0.3 cc) tissue filaments were injected into the sites through each port as the needle was withdrawn. Approximately 100 cc PRP-adipose tissue was distributed as filaments into the subpectoral plane, another 100 cc was injected in a similar fashion into the plane of the pectoralis muscle, and 100 cc was injected into
the retroglandular space below the parenchyma breast tissue (Fig. 6). Between syringes the breast tissue was gently massaged to disperse any globules. If one breast measurement was larger than the other, more adipose tissue was infiltrated into the smaller breast to adjust the size. Patients were given 9-12 mg betamethasone (Celestone, Schering Corp., NJ) intramuscularly to reduce inflammation, as well as routine postoperative oral antibiotics, analgesics, and sleeping pills.
Following the procedure the donor sites were placed into a compression garment. The breasts were placed in a firm support bra. These garments or similar compression girdles were worn for approximately 1 month. Patients were seen at 3 and 6 months and annually thereafter for photography and volumetric breast measurements. Mammograms were done annually.
RESULTS
The platelet-enriched fibrin clot dehydrated the adipose tissue, enmeshed the fat cells, and coated them in fibrin and platelet-derived growth factors. In the 65 cases studied (age range, 18-72 years; average age, 38) this produced a breast augmentation equivalent to a 200-250 cc implant (Figs. 7-9). We were surprised to find only minimal bruising and pain in the breast area during the immediate follow-up period. There were no hematomas or fat emboli. Two patients experienced striae of the breasts that improved with daily application of tretinoin (Retin-A Cream, 0.1%, Ortho Derma-tological, Raritan, NJ). Repeated volumetric measurements documented an average residual augmented breast volume of 73% in these cases (Fig. 10) compared to 63% before the utilization of PRP/6) Tissue biopsies demonstrated only healthy fatty tissue.
Mammographic findings
The radiologist documented fatty infiltration of the pectoralis muscle and the prepectoral space. There was no masking or compression of breast tissue (Figure 11 A). Benign "eggshell" calcifications occurred in 9% of the cases (Fig. 11B). These were usually bilateral. No cases of small spiculed calculi indicating possible malignancy occurred.
In summary, there was some loss of breast volume as the transfer fluid dissipated during the initial 60-90 days after surgery. Thereafter, the volume was constant except for the usual changes seen during the menstrual cycles or with weight loss or weight gain (Fig. 12). Twenty percent of the patients ended up with volumes greater than 100% because of weight gain and the natural increase in breast volume with liposuction/19) Conversely, patients with ptotic breasts of greater than 5 cm or thin patients did not retain fat as well.
DISCUSSION
The best results were obtained in the mature women who had several children, breasts that were atrophic but not ptotic, areas of dysharmonious obesity, and would be content with a one-cup size increase in volume. The addition of the PRP maximized the transplant efficiency by adding growth factors and reducing the excessive tumescent fluid. This dehydration of the adipose tissue was probably related to the addition of albumin from the PRP, which replenished the extracellular osmotic pressure as suggested by Kaminsky/20) Forty to 60% of the supernatant fat volume was released and passed through the sieve as blood-tinged fluid and free lipids. This may explain why it was only possible to achieve 40-60% volume retention with atypical fat transfer/21) This extra tumescent fluid would eventually be eliminated in vivo, yielding disappointed results. A maximum retention of 70-80% would be predicted as the volume of the platelet gel may also dissipates with time. The larger than 100% retention volumes occurred later in some cases as the fat cells gained volume/19)
To achieve satisfactory results with this technique, the thin patient with low estrogen levels and no areas of dysharmonious obesity should be avoided. Also avoid the patient with ptotic breasts. Our adipose augmentations have been disappointing in these cases. Beyond 5-7 cm ptosis, the circulation and lymphatic drainage in the breast appeared compromised. This dependent breast does not appear to support the implanted tissue as well as the non-ptotic breast. These cases may need mastopexy at least 6 months before the augmentation.
Breast contouring with "gelled" autologous fat is a realistic addition to the breast augmentation armamentarium. Autologous tissue avoids the risk of capsule formation or possible reactions from leaking silicone implants. The original concerns involving fat augmentation (2T> have not developed. To date, no distortion of breast tissue or masking of breast tissue has been seen with mammogram (Table 1). There is a higher risk of "blinding" the breast or the development of benign calcifications with a silicone prosthesis. (23)
Factors that maximize fat retention are blood-free harvesting methods, using tumescent liposuction with a low vacuum "vented" syringe, washing away any debris from the adipose tissue, using PRP to stabilize the adipose implant, and spreading the fat cells into small aliquots in
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