COSMETIC Breast Augmentation Using Preexpansion and Autologous Fat Transplantation: A Clinical Radiographic Study Daniel A. Del Vecchio, Background: Despite the increased popularity of fat grafting of the breasts, M.D., M.B.A. there remain unanswered questions. There is currently no standard for tech- Louis P. Bucky, M.D. nique or data regarding long-term volume maintenance with this procedure. Boston, Mass.; and Philadelphia, Pa. Because of the sensitive nature of breast tissue, there is a need for radiographic evaluation, focusing on volume maintenance and on tissue viability. This study was designed to quantify the long-term volume maintenance of mature adi- pocyte fat grafting for breast augmentation using recipient-site preexpansion. Methods: This is a prospective examination of 25 patients in 46 breasts treated with fat grafting for breast augmentation from 2007 to 2009. Indications in- cluded micromastia, postexplantation deformity, tuberous breast deformity, and Poland syndrome. Preexpansion using the BRAVA device was used in all patients. Fat was processed using low–g-force centrifugation. Patients had pre- operative and 6-month postoperative three-dimensional volumetric imaging and/or magnetic resonance imaging to quantify breast volume. Results: All women had a significant increase in breast volume (range, 60 to 200 percent) at 6 months, as determined by magnetic resonance imaging (n ϭ 12), and all had breasts that were soft and natural in appearance and feel. Magnetic resonance imaging examinations postoperatively revealed no new oil cysts or breast masses. Conclusions: Preexpansion of the breast allows for megavolume (Ͼ300 cc) grafting with reproducible, long-lasting results that can be achieved in less than 2 hours. These data can serve as a benchmark with which to evaluate the safety and efficacy of other core technology strategies in fat grafting. The authors believe preexpansion is useful for successful megavolume fat grafting to the breast. (Plast. Reconstr. Surg. 127: 2441, 2011.) ecent evidence from a variety of indepen- breasts, and cautioned that “results of fat transfer dent investigators1,2 suggests that fat grafting remain dependent on a surgeon’s technique and Rto the breast is a procedure that can yield expertise.”3 The use of preexpansion of the breast natural, long-term results. Because of unknown recipient site before grafting has been suggested potential long-term effects of fat transplantation to yield impressive long-term volume mainte- into the breast, careful study is warranted. In Jan- nance4; however, there are currently few to no uary of 2009, the American Society of Plastic Sur- published data with which to evaluate this on an geons revised their position on fat grafting to the objective basis. The purpose of the present study was to quantify the clinical results of nonsurgical preexpansion and autologous fat grafting in From private practice. breast augmentation. Received for publication May 20, 2010; accepted September 21, 2010. PATIENTS AND METHODS Presented at the 27th Annual Meeting of the Northeastern From 2007 to 2009, 25 patients (46 breasts in Society of Plastic Surgeons, in Charleston, South Carolina, total) desiring breast augmentation were selected September 23 through 27, 2009. Reprinted and reformatted from the original article published with the June 2011 issue (Plast Reconstr Surg. 2011;127: 2441–2450). Disclosure: The authors have no financial interest Copyright ©2012 by the American Society of Plastic Surgeons to declare in relation to the content of this article. DOI: 10.1097/PRS.0b013e31825091f0 66S www.PRSJournal.com Volume 129, Number 5S • Breast Augmentation Using Preexpansion to undergo autologous fat grafting. Patients ranged Immediately following preexpansion, and af- in age from 21 to 60 years. Some exhibited severe ter the patients gave their written and verbal in- unilateral asymmetry caused by Poland syndrome formed consent, patients underwent autologous or other growth-related asymmetries. Patients fat transplantation. No high-speed centrifugation were initially photographed and underwent three- was used to process fat in this patient series. Fat was dimensional breast imaging and/or breast mag- allowed to separate from unwanted crystalloid and netic resonance imaging using intravenous gado- was then centrifuged at low g forces (20 to 40 g). linium contrast in a 4-T breast coil (Department of A range of 220 to 550 cc of fat per session was Radiology and Breast Imaging, Boston University injected into each breast. Medical Center, Boston, Mass.). In the first 24 hours after grafting, there was no external compression or negative pressure used. Use of BRAVA Preexpansion before Beginning at 24 to 48 hours after grafting, patients Fat Grafting were placed back into BRAVA domes, which were Under institutional review board approval, pa- placed under low battery pump suction. Patients tients underwent preoperative nonsurgical breast wore their external expansion devices for 2 to 4 expansion for a period of 3 weeks by means of an weeks postoperatively and were followed up at reg- external expansion device (BRAVA, LLC, Miami, ular intervals. Patients underwent a second post- Fla.). The device consisted of a rigid plastic dome operative magnetic resonance imaging examina- with silicone gel cushioning at the base and with tion 6 months after their fat grafting session to tubing connected to a negative-pressure pump evaluate tissue viability, volume maintenance, and (Fig. 1). Expansion programs were individualized parenchymal abnormalities. for each patient based on lifestyle analysis and psychological compliance testing. Patients who Quantitative Results: Objective could not comply with their programs had their Volume Measurements target dates for surgery extended to achieve proper preexpansion. Patients who completed both preoperative and 6-month postoperative breast magnetic reso- Patients were followed closely during preop- ϭ erative expansion with serial inpatient examina- nance imaging (n 12) provided volumetric data tions and three-dimensional breast imaging. They sets that were subjected to analysis. All magnetic were encouraged to overexpand according to resonance imaging scans were read and all quan- their desired final breast volume, following the titative magnetic resonance imaging analyses “1-2-3 rule” (Fig. 2). were performed independently by the same ra- diologist. The radiologist responsible for all magnetic resonance imaging readings was em- ployed at an academic medical center that was chosen on the basis of magnetic resonance im- aging cost in the primary author’s (D.A.D.V.) geographic area. Neither author was affiliated with this academic medical center. Baseline pre- expansion volumes and 6-month postoperative volumes were measured using the semiauto- mated computer-generated method of volume measurement, which is considered to be the most accurate method of quantifying breast vol- umes by magnetic resonance imaging.5 The average preoperative volume of the breasts measured by magnetic resonance imaging in this study was 284 cc. The average 6-month postoperative breast volume was 557 cc, for an average increase in volume of 272 cc. On a per- centage increase basis, this represented a 106 per- Fig. 1. The BRAVA external tissue expander worn by a patient cent increase, or a two-fold increase in breast vol- just before the fat grafting procedure. Note that the expanded ume on average. Because different clinical goals breast tissue is almost in contact with the domes. Fogging of the existed in each patient, there was a range of vol- domes because of evaporative water loss is normal. ume increases at 6 months after grafting (107 to 67S Plastic and Reconstructive Surgery • Spring 2012 Fig. 2. The “1-2-3 rule” states that if you are a 1 and you want to be a 2, you must expand to a 3. A patient (left) who wants to double final volume at 6 months (center) must triple in expansion (right). Patients should not expand to their desired breast volume but should hyperexpand and surpass their desired size to achieve optimal results. 345 cc). Subjecting the data to paired, open-ended was small, suggesting reliability of the technique in t testing, the difference between the preoperative terms of obtaining symmetry. The raw data set is and 6-month postoperative results was statistically provided in Table 1. significant, with a value of p ϭ 0.0000003. In any The average procedure time was 2 hours. Ini- given patient, volume increases were similar, and tially, the procedures took over 2 hours; however, the variance between increases in breast volume after an initial learning curve, procedures took Table 1. Raw Volumetric Data Sets from Quantitative Magnetic Resonance Imaging Scans in 12 Patients Showing Methodology of Preexpansion and 6-Month Postoperative Breast Volumes* Clinical Data Volumetric Data Patient Age (yr) Indication for Surgery Breast Before After Change Increase (%) Graft Yield (%) 1† 34 Tuberous breasts Left 383 684 301 79 600 50 Right 385 686 301 78 600 50 2† 29 Tuberous breasts Left 240 585 345 144 600 58 Right 289 611 322 111 600 54 3 35 Postpartum deflation Left 267 518 251 94 380 66 Right 251 479 228 91 380 60 4 21 Severe breast asymmetry Left 107 337 230 215 220 105 5 26 Micromastia Left 156 463 307 197 420 73 Right 166 476 310 187 420 74 6 30 Postpartum deflation Left 351 565 214 61 360 59 Right 338 552 214 63 360 59 7 42 Poland syndrome Right 332 720 388 117 450 86 8 28 Micromastia Left 350 638 288 82 430 67 Right 396 698 302 76 430 70 9 25 Micromastia Left 333 586 253 76 450 56 Right 300 553 253 84 450 56 10 41 Micromastia Left 97 204 107 110 230 47 Right 104 227 123 118 230 53 11 60 Explantation of prostheses Left 225 428 203 90 380 53 Right 261 498 237 91 380 62 12 45 Postpartum deflation Left 498 927 429 86 550 78 Right 427 808 381 89 550 69 Average‡ 284 557 272 106 430 64 SD 13 *Cases with only one data set represent unilateral breast augmentation because of severe developmental asymmetry.