Bicompartmental breast lipostructuring.

The techniques of additive mastoplasty described 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 autologous 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 retroglandular and prefascial space and into the superficial subcutaneous plane of the upper pole of the breast (bicompartmental grafting). Any intraparenchymal placement is carefully avoided. Since 1998, 181 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 preoperative and serial postoperative mammograms and ultrasonograms. This strict follow-up assessment allowed the authors to clarify the controversial aspect of microcalcifications, 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 discriminated 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 differentiate into preadipocytes and then into adipocytes, compensating for the partial loss of mature adipocytes reabsorbed through time. This theory has been well demonstrated 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 differentiated 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 controversial 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 either unsuitable or unacceptable by the patient herself. However this method cannot be considered yet as a complete substitute for augmentation with implants because the degree of augmentation and projection still is limited.

Basic physics for ultrasound-assisted lipoplasty.

To apply ultrasound energy to the human body for the purpose of creating a surgical effect, it is imperative that the basic laws of nature that govern the interaction of sound on various media be clearly understood; otherwise, the operator will fail to appreciate the mechanism by which the desired result can be best obtained. This article reviews the physical principle, tissue interactions, wave properties, equipment, and biologic and micromechanical effects of ultrasound-assisted lipoplasty. Ultimately, the technique is based on the perfect control and balance between the thermal effect and cavitational phenomenon.

The tissue effects of ultrasound-assisted lipoplasty.

The objective of our study was to investigate the effects of ultrasonic energy on tissues, using a porcine model, performed under various instrumental and procedural parameters. Domestic pigs were anesthetized and prepared for surgery. An incision was made on the side of the hip randomly assigned to the right or left side. Tumescence solution was infiltrated via a blunt tip, small diameter cannula, followed by performance of standard liposuction. On the contralateral side, a similar incision was made. For ultrasonic liposuction experiments without the sheath, a percutaneous introducer was inserted into the incision, which was protected at the entry site from contact with the cannula. Tumescence solution was infiltrated via a blunt tip, small diameter cannula, and then the site was treated with ultrasonic energy at maximum output from the machine with liposuction concurrent through the hollow cannula. The experiments with the sheath did not require a pretreatment with tumescence solution but consisted of tumescence solution pumped through the sheath at a low infusion rate, with concurrent treatment utilizing ultrasonically assisted liposuction through the central lumen of the cannula. In all cases, the lipoaspirate was preserved for biochemical analysis. After treatment, the pigs were euthanized, and samples for histopathology were taken. The pigs were then perfused with a radio-opaque solution through the left ventricle following preperfusion with saline. The groups were ultrasound-assisted liposuction with sheath (n = 3), ultrasound-assisted without sheath (n = 4), and tumescence alone (n = 1), with standard liposuction performed on the contralateral side for all ultrasound-assisted liposuction animals. The lipoaspirates from the ultrasonically assisted liposuction with the sheath showed significantly less blood loss (measured as hemoglobin in the aspirate) than standard liposuction (p = 0.012) at comparable levels of fat (measured as triglycerides in the aspirate). The lipoaspirates from ultrasound-assisted liposuction without the sheath showed blood loss comparable to that experienced with standard liposuction. The ratio of hemoglobin to triglyceride was lowest in the ultrasound-assisted group with (p = 0.01) and without (p = 0.06) the sheath when compared to traditional liposuction. In both of these treated groups, the radiograms of the perfused areas showed significantly less vascular disruption when compared with suction-assisted liposuction. Histopathologic examination of specimens taken from various treated areas showed substantial tissue damage comparable in ultrasound- and suction-assisted liposuction treated groups. This preliminary experimental study showed that ultrasound-assisted lipoplasty is comparable to traditional suction-assisted lipoplasty. Treatment with ultrasound provided more significant hemoglobin/triglyceride ratios, indicative of more lipid aspirated per hemoglobin lost, and better preservation of vascular tissues as demonstrated by our perfusion studies. Treatment with the sheath showed a significantly lower hemoglobin release with a diminished volume infused into the subcutaneous space during the procedure.

Ultrasonic assisted lipoplasty. Technical refinements and clinical evaluations.

Since the late 1970s, when suction-assisted lipoplasty was developed, many surgeons have tried to improve methodology to get more predictable results and reduce potential side effects and complications. Ultrasonic assisted lipoplasty, in which fat tissues are selectively targeted by the surgical action, represents the most advanced and innovative evolution of traditional liposuction, offering reduced trauma and blood loss and a more specific and complete treatment of the very superficial fat layers. The author describes the physical and technical principles of this technique, with a complete overview of his clinical experience, including tricks, traps, and complications.