Editing Breast augmentation (section)

==Non-implant breast augmentation==
Non-implant breast augmentation with injections of autologous fat grafts (adipocyte tissue) is indicated for women requiring [[breast reconstruction]], [[Congenital defect|defect correction]], and the æsthetic enhancement of the bust.
* breast reconstruction: post-mastectomy re-creation of the breast(s); trauma-damaged tissues (blunt, penetrating), disease ([[breast cancer]]), and explantation deformity (empty breast-implant socket).
* congenital defect correction: [[micromastia]], [[tuberous breast deformity]], [[Poland Syndrome|Poland's syndrome]], etc.
* primary augmentation: the aesthetic enhancement (contouring) of the size, form, and feel of the breasts.

The [[operating room]] time of breast reconstruction, congenital defect correction, and primary breast augmentation procedures is determined by the indications to be treated.

The advent of [[liposuction]] technology facilitated medical applications of the liposuction-harvested fat tissue as autologous filler for injection to correct bodily defects, and for breast augmentation. Melvin Bircoll introduced the practice of contouring the breast and for correcting bodily defects with autologous fat grafts harvested by liposuction; and he presented the fat-injection method used for emplacing the fat grafts.<ref>Bircoll M. Autologous Fat Transplantation (presentation) The Asian Congress of Plastic Surgery, February 1982</ref><ref>Bircoll MJ (1984) New Frontiers in Suction Lipectomy (presentation) Second Asian Congress of Plastic Surgery, Pattiya, Thailand, February</ref> In 1987, the Venezuelan plastic surgeon Eduardo Krulig emplaced fat grafts with a syringe and blunt needle (lipo-injection), and later used a disposable fat trap to facilitate the collection and to ensure the sterility of the harvested adipocyte tissue.<ref>{{cite journal |last1=Krulig |first1=Eduardo |title=Lipo-injection |journal=American Journal of Cosmetic Surgery |year=1987 |volume=4 |issue=2 |pages=123–9|doi=10.1177/074880688700400206 }}</ref><ref>[[#Schiffman|Schiffman]], p. 4.</ref>

To emplace the grafts of autologous fat-tissue, doctors J. Newman and J. Levin designed a lipo-injector gun with a gear-driven plunger, which allowed the even injection of autologous fat-tissue to the desired recipient sites. The control afforded by the lipo-injector gun assisted the plastic surgeon in controlling excessive pressure to the fat in the barrel of the syringe, thus avoiding over-filling the recipient site.<ref>{{cite journal|vauthors=Newman J, Levin J |title=Facial Lipo-transplant Surgery|journal= American Journal of Cosmetic Surgery|year= 1987|volume= 4|issue=2|pages=131–140|doi=10.1177/074880688700400207|s2cid=57412119}}</ref> The later-design lipo-injector gun featured a ratchet-gear operation that afforded the surgeon greater control in accurately emplacing grafts of autologous fat to the recipient site; a trigger action injected 0.1&nbsp;cm<sup>3</sup> of filler.<ref>{{cite journal|author=Agris J. |title=Autologous Fat Transplantation: A Three-year Study|journal= American Journal of Cosmetic Surgery |year=1987|volume= 4|issue=2|pages= 95–102|doi=10.1177/074880688700400203|s2cid=79454414}}</ref> Since 1989, most non-surgical, fat-graft augmentations of the breast employ adipocyte fat from sites other than the breast, up to 300&nbsp;ml of fat in three equal injections, is placed into the subpectoral space and the intrapectoral space of the [[pectoralis major muscle]], as well as the submammary space, to achieve a breast outcome of natural appearance and contour.<ref>[[#Schiffman|Schiffman]], p. 226.</ref>

===Autologous fat grafting===
{{update section|reason= sources 17 years old|date=January 2024}}
The technique of autologous fat-graft injection to the [[breast]] is applied for the correction of breast asymmetry or deformities, for [[Mastectomy|post-mastectomy]] [[breast reconstruction]] (as a primary and as an adjunct technique), for the improvement of soft-tissue coverage of breast implants, and for the aesthetic enhancement of the bust. The careful harvesting and [[centrifuge|centrifugal]] refinement of the mature adipocyte tissue (injected in small aliquots) allows the transplanted fat tissue to remain viable in the breast, where it provides the anatomical structure and the hemispheric contour that cannot be achieved solely with breast implants or with corrective plastic surgery.{{cn|date=July 2024}}

[[File:Dr. Placik Chicago Breast Fat Grafting 19097.jpg|thumb|right|350px|Non-implant breast augmentation: the pre-procedural aspects (left) and the post-procedural aspects (right) of breasts enlarged and contoured with autologous fat grafts]]

In fat-graft breast augmentation procedures, there is the risk that the [[Adipose tissue|adipocyte tissue]] grafted to the breast(s) can undergo [[necrosis]], [[metastatic calcification]], develop cysts, and agglomerate into palpable lumps. Although the cause of metastatic calcification is unknown, the post-procedure biological changes occurred to the fat-graft tissue resemble the tissue changes usual to breast surgery procedures such as [[breast reduction|reduction mammoplasty]]. The French study ''Radiological Evaluation of Breasts Reconstructed with Lipo-modeling'' (2005) indicates the therapeutic efficacy of fat-graft breast reconstruction in the treatment of [[radiation therapy]] damage to the chest, the incidental reduction of [[capsular contracture]], and the improved soft-tissue coverage of breast implants.<ref>{{cite journal | author = Pierrefeu-Lagrange A. C. |author2=Delay E. |author3=Guerin N.|display-authors=et al | year = 2005 | title = Radiological Evaluation of Breasts Reconstructed with Lipo-modeling (in French) | journal = Annales de Chirurgie Plastique et Esthétique | volume = 51 | issue = 1|pages=18–28 | doi=10.1016/j.anplas.2005.10.001|pmid=16338046 }}</ref><ref>{{cite journal | author = Rigotti G. |author2=Marchi A. |author3=Galiè M.|display-authors=et al | year = 2007| title = Clinical Treatment of Radiotherapy Tissue Damages by Lipoaspirates Transplant: A Healing Process Mediated by Adipose-derived Stem cells (ASCS) | journal = Plastic and Reconstructive Surgery | volume =  119| issue = 5| pages = 1409–22; discussion 1423–4| doi=10.1097/01.prs.0000256047.47909.71| pmid = 17415234|s2cid=24897504 }}</ref><ref>{{cite journal | author = Massiha H | year = 2002 | title = Scar-tissue Flaps for the Correction of Post-implant Breast Rippling | journal = Annals of Plastic Surgery | volume = 48 | issue = 5| pages = 505–7 | doi=10.1097/00000637-200205000-00009| pmid = 11981190 | s2cid = 31590174 }}</ref>

The study ''Fat Grafting to the Breast Revisited: Safety and Efficacy'' (2007) reported successful transfers of body fat to the [[breast]], and proposed the fat-graft injection technique as an alternative (i.e., non-implant) augmentation mammoplasty procedure instead of the surgical procedures usual for effecting breast augmentation, breast defect correction, and breast reconstruction.{{cn|date=July 2024}}

Structural fat-grafting was performed either to one breast or to both breasts of the 17 women; the age range of the women was 25–55 years; the mean age was 38.2 years; the average volume of a tissue-graft was 278.6&nbsp;cm<sup>3</sup> of fat per operation, per breast.{{cn|date=July 2024}}

The pre-procedure mammograms were negative for [[Breast cancer|malignant neoplasms]]. In the 17-patient cohort, it was noted that two women developed [[breast cancer]] (diagnosed by [[Mammography|mammogram]]) post-procedure: one at 12 months, and the other at 92 months.<ref name=Coleman>{{Cite journal | last1 = Coleman | first1 = S. R. | last2 = Saboeiro | first2 = A. P. | s2cid = 1950274 | doi = 10.1097/01.prs.0000252001.59162.c9 | title = Fat Grafting to the Breast Revisited: Safety and Efficacy | journal = Plastic and Reconstructive Surgery | volume = 119 | issue = 3 | pages = 775–785; discussion 785–7 | year = 2007 | pmid = 17312477 }}</ref> Further, the study ''Cell-assisted Lipotransfer for Cosmetic Breast Augmentation: Supportive Use of Adipose-Derived Stem/Stromal Cells'' (2007), an approximately 40-woman cohort indicated that the inclusion of adipose [[stem cells]] in the grafts of adipocyte fat increased the rate of corrective success of the autologous fat-grafting procedure.<ref>{{Cite journal | last1 = Yoshimura | first1 = K. | last2 = Sato | first2 = K. | last3 = Aoi | first3 = N. | last4 = Kurita | first4 = M. | last5 = Hirohi | first5 = T. | last6 = Harii | first6 = K. | doi = 10.1007/s00266-007-9019-4 | title = Cell-Assisted Lipotransfer for Cosmetic Breast Augmentation: Supportive Use of Adipose-Derived Stem/Stromal Cells | journal = Aesthetic Plastic Surgery | volume = 32 | issue = 1 | pages = 48–55; discussion 56–7 | year = 2007 | pmid = 17763894 | pmc =2175019 }}</ref>

===Fat grafting techniques===
====Fat harvesting and contouring====

The centrifugal refinement of the liposuction-harvested adipocyte tissues removes blood products and free [[lipids]] to produce autologous breast filler. The injectable filler-fat is obtained by centrifuging (spinning) the fat-filled syringes for sufficient time to allow the serum, blood, and oil (liquid fat) components to collect, by density, apart from the refined, injection-quality fat.<ref>{{cite journal|author=Asken, S.|title=Autologous Fat Transplantation: Micro and Macro Techniques|journal= American Journal of Cosmetic Surgery |year=1987|volume= 4|issue=2|pages=111–121|doi=10.1177/074880688700400205|s2cid=79451948}}</ref> To refine the fat for facial injection quality, the fat-filled syringes are centrifuged for 1.0 minute at 2,000 RPM, which separates the unnecessary solution, leaving refined filler-fat.<ref>{{Cite journal | last1 = Toledo | first1 = L. S. | title = Syringe liposculpture: A two-year experience | journal = Aesthetic Plastic Surgery | volume = 15 | issue = 4 | pages = 321–326 | year = 1991 | pmid = 1950806| doi = 10.1007/BF02273880 | s2cid = 33827789 }}</ref> Moreover, centrifugation at 10,000 RPM for 10 minutes produces a "collagen graft"; the [[Histology|histologic]] composition of which is [[Cell (biology)|cell]] residues, [[collagen]] fibres, and 5.0 percent intact fat cells. Furthermore, because the patient's body naturally absorbs some of the fat grafts, the breasts maintain their contours and volumes for 18–24 months.<ref>Uebel, C.O. (1992) "Facial Sculpture with Centrifuged fat Collagen", pp. 749–752 in Hinder, V.T. (Ed.) ''Plastic Surgery'' Vol. II. Amsterdam Excerpta Medica</ref><ref>[[#Schiffman|Schiffman]], p. 5.</ref>

[[File:20845 Dr. Placik Chicago Arlington Heights Illinois Fat Grafting Breasts.jpg|thumb|right|350px|Fat-graft breast augmentation: the pre-operative aspects (left) and the post-operative aspects (right) of a large-volume non-surgical augmentation]]

In the study ''Fat Grafting to the Breast Revisited: Safety and Efficacy'' (2007), the investigators reported that the autologous fat was harvested by liposuction, using a 10-ml syringe attached to a two-hole Coleman harvesting [[cannula]]; after centrifugation, the refined breast filler fat was transferred to 3-ml syringes. Blunt infiltration cannulas were used to emplace the fat through 2-mm incisions; the blunt cannula injection method allowed greater dispersion of small aliquots (equal measures) of fat, and reduced the possibility of intravascular fat injection; no sharp needles are used for fat-graft injection to the breasts. The 2-mm incisions were positioned to allow the infiltration (emplacement) of fat grafts from at least two directions; a 0.2&nbsp;ml fat volume was emplaced with each withdrawal of the cannula.<ref>{{Cite journal | last1 = Coleman | first1 = S. | title = Avoidance of arterial occlusion from injection of soft tissue fillers | doi = 10.1067/maj.2002.129625 | journal = Aesthetic Surgery Journal | volume = 22 | issue = 6 | pages = 555–557 | year = 2002 | pmid = 19332014 | doi-access = free }}</ref>

The breasts were contoured by layering the fat grafts into different levels within the breast, until achieving the desired breast form. The fat-graft injection technique allows the plastic surgeon precise control in accurately contouring the breast{{snd}}from the chest wall to the breast skin envelope{{snd}}with subcutaneous fat grafts to the superficial planes of the breast. This greater degree of breast sculpting is unlike the global augmentation realised with a breast implant emplaced below the breast or below the pectoralis major muscle, respectively expanding the [[retromammary space]] and the retropectoral space. The greatest proportion of the grafted fat usually is infiltrated to the pectoralis major muscle, then to the retropectoral space, and to the prepectoral space, (before and behind the pectoralis major muscle). Moreover, although fat grafting to the breast [[parenchyma]] usually is minimal, it is performed to increase the degree of projection of the [[Cleavage (breasts)|bust]].<ref name=Coleman/>

====Fat-graft injection====
The biologic survival of autologous fat [[Tissue (biology)|tissue]] depends upon the correct handling of the fat graft, of its careful washing (refinement) to remove extraneous blood cells, and of the controlled, blunt-cannula injection (emplacement) of the refined fat-tissue grafts to an adequately [[Circulatory system|vascularized]] recipient site. Because the body resorbs some of the injected fat grafts (volume loss), compensative over-filling aids in obtaining a satisfactory breast outcome for the patient; thus the transplantation of large-volume fat grafts greater than required, because only 25–50 percent of the fat graft survives at 1-year post-transplantation.<ref>{{cite journal | author = Guerney C.E. | year = 1938 | title = Experimental Study of the Behavior of Free fat Transplants | journal = Surgery | volume = 3 | pages = 679–692 }}</ref>

The correct technique maximizes fat graft survival by minimizing [[Cell (biology)|cellular]] trauma during the liposuction harvesting and the centrifugal refinement, and by injecting the fat in small aliquots (equal measures), not clumps (too-large measures). Injecting minimal-volume aliquots with each pass of the [[cannula]] maximizes the surface area contact, between the grafted fat-tissue and the recipient breast-tissue, because proximity to a vascular system ([[Circulatory system|blood supply]]) encourages [[Histology|histologic]] survival and minimizes the potential for fat necrosis.<ref name=Coleman/> Transplanted autologous fat tissue undergoes histologic changes like those undergone by a bone transplant; if the body accepts the fat-tissue graft, it is replaced with new fat tissue, if the fat-graft dies it is replaced by [[Fibrous connective tissue|fibrous tissue]]. New fat tissue is generated by the activity of a large, wandering [[Histiocyte|histocyte]]-type [[Cell (biology)|cell]], which ingests fat and then becomes a fat cell.<ref>Neuhof H. (1923) ''The Transplantation of Tissues'' New York:D. Appleton p. 74</ref> When the breast-filler fat is injected to the breasts in clumps (too-large measures), fat cells emplaced too distant from blood vessels might die, which can lead to fat tissue necrosis, causing lumps, calcifications, and the eventual formation of liponecrotic cysts.

[[File:21327 Dr. Placik Chicago Arlington Heights IL Breast AUgmentation Fat Grafting.jpg|thumb|right|350px|Fat-graft breast augmentation: the pre-operative aspects (left) and the post-operative aspects (right) of a medium-volume non-surgical augmentation]]

The operating room time required to harvest, refine, and emplace fat to the breasts is greater than the usual 2-hour OR time; the usual infiltration time was approximately 2 hours for the first 100&nbsp;cm<sup>3</sup> volume, and approximately 45 minutes for injecting each additional 100&nbsp;cm<sup>3</sup> volume of breast-filler fat. The technique for injecting fat grafts for breast augmentation allows the plastic surgeon great control in sculpting the breasts to the required contour, especially in the correction of [[tuberous breast deformity]]. In which case, no fat-graft is emplaced beneath the nipple-areola complex (NAC), and the skin envelope of the breast is selectively expanded (contoured) with subcutaneously emplaced body-fat, immediately beneath the skin. Such controlled contouring selectively increased the proportional volume of the breast in relation to the size of the nipple-areola complex, and thus created a breast of natural form and appearance; greater verisimilitude than is achieved solely with breast implants. The fat-corrected, breast-implant deformities, were inadequate soft-tissue coverage of the implant(s) and [[capsular contracture]], achieved with subcutaneous fat-grafts that hid the implant-device edges and wrinkles, and decreased the palpability of the underlying breast implant. Furthermore, grafting autologous fat around the breast implant can result in softening the breast capsule.<ref>Rigotti G, Marchi A, Galiè M. et al. Clinical Treatment of Radiotherapy Tissue Damages by Lipoaspirates Transplant: a Healing Process Mediated by Adipose-derived stem cells (ASCS). Plastic and Reconstructive Surgery (accepted for publication).</ref>

====External tissue expansion====
The successful outcome of fat-graft breast augmentation is enhanced by achieving a pre-expanded recipient site to create the breast-tissue [[Matrix (biology)|matrix]] that will receive grafts of autologous adipocyte fat. The recipient site is expanded with an external vacuum tissue-expander applied upon each breast. The biological effect of negative pressure ([[vacuum]]) expansion upon [[soft tissues]] derives from the ability of soft tissues to grow when subjected to controlled, distractive, mechanical forces. (see [[distraction osteogenesis]]) The study reported the technical effectiveness of recipient-site pre-expansion. In a single-group study, 17 healthy women (aged 18–40 years) wore a brassiere-like vacuum system that applied a 20-mmHg vacuum (controlled, mechanical, distraction force) to each breast for 10–12 hours daily for 10 weeks. Pre- and post-procedure, the breast volume (size) was periodically measured; likewise, a magnetic resonance image ([[MRI]]) of the breast-tissue architecture and water density was taken during the same phase of the patient's [[menstrual cycle]]; of the 17-woman study group, 12 completed the study, and 5 withdrew, because of non-compliance with the [[clinical trial protocol]].<ref name="ReferenceA">{{Cite journal | last1 = Khouri | first1 = R. K. | last2 = Schlenz | first2 = I. | last3 = Murphy | first3 = B. J. | last4 = Baker | first4 = T. J. | title = Nonsurgical breast enlargement using an external soft-tissue expansion system | journal = Plastic and Reconstructive Surgery | volume = 105 | issue = 7 | pages = 2500–2512; discussion 2512–4 | year = 2000 | pmid = 10845308 | doi=10.1097/00006534-200006000-00032| s2cid = 12772558 }}</ref>

The breast volume (size) of all 17 women increased throughout the 10-week treatment period, the greatest increment was at week 10 (final treatment){{snd}}the average volume increase was 98+/–67 percent over the initial breast-size measures. Incidences of partial recoil occurred at 1-week post-procedure, with no further, significant, breast volume decrease afterwards, nor at the follow-up treatment at 30-weeks post-procedure. The stable, long-term increase in breast size was 55 percent (range 15–115%). The MRI visualizations of the breasts showed no [[edema]], and confirmed the proportionate enlargement of the adipose and glandular components of the breast-tissue [[Matrix (biology)|matrices]]. Furthermore, a statistically significant decrease in body weight occurred during the study, and [[self-esteem]] questionnaire scores improved from the initial-measure scores.<ref name="ReferenceA"/>

Because external vacuum expansion of the recipient-site tissues permits injecting large-volume fat grafts (+300&nbsp;cc) to correct defects and enhance the bust, the [[Histology|histologic]] viability of the breast filler (adipocyte fat) and its volume must be monitored and maintained. The long-term, volume maintenance data reported in ''Breast Augmentation using Pre-expansion and Autologous Fat Transplantation: a Clinical Radiological Study'' (2010) indicate the technical effectiveness of external tissue expansion of the recipient site for a 25-patient study group, who had 46 breasts augmented with fat grafts. The indications included [[micromastia]] (underdevelopment), explantation deformity (empty implant pocket), and congenital defects ([[tuberous breast deformity]], [[Poland syndrome|Poland's syndrome]]).<ref name="Del Vecchio D pp. 68"/>

Pre-procedure, every patient used external vacuum expansion of the recipient-site tissues to create a breast tissue matrix to be injected with autologous fat grafts of adipocyte tissue, refined via low G-force centrifugation. Pre- and post-procedure, the breast volumes were measured; the patients underwent pre-procedure and 6-month post-procedure MRI and [[X-ray computed tomography|3D volumetric imaging]] examinations. At six months post-procedure, each woman had a significant increase in breast volume, ranging 60–200 percent, per the MRI (n=12) examinations. The size, form, and feel of the breasts was natural; post-procedure MRI examinations revealed no oil [[cysts]] or [[Breast diseases|abnormality]] ([[neoplasm]]) in the fat-augmented breasts. Moreover, given the sensitive, biologic nature of breast tissue, periodic MRI and 3-D volumetric imaging examinations are required to monitor the breast-tissue viability and the maintenance of the large volume (+300&nbsp;cc) fat grafts.<ref name="Del Vecchio D pp. 68"/>

===Post-mastectomy procedures===
Surgical post-mastectomy [[breast reconstruction]] requires general anaesthesia, cuts the chest muscles, produces new scars, and requires a long post-surgical recovery for the patient. The surgical emplacement of breast implant devices (saline or silicone) introduces a foreign object to the patient's body (see [[capsular contracture]]). The [[TRAM flap]] (Transverse Rectus Abdominis Myocutaneous flap) procedure reconstructs the breast using an autologous flap of abdominal, cutaneous, and muscle tissues. The latissimus myocutaneous flap employs skin fat and muscle harvested from the back, and a breast implant. The [[DIEP flap]] (Deep Inferior Epigastric Perforators) procedure uses an autologous flap of abdominal skin and fat tissue.<ref name="Khouri RK 2010">Khouri RK (2010) Non-surgical breast reconstruction with autologous fat-grafts</ref>{{incomplete reference|date=January 2024}}

====Post-mastectomy fat-graft reconstruction====
The reconstruction of the breast(s) with grafts of autologous fat is a non-implant alternative to further surgery after a breast cancer surgery, be it a [[lumpectomy]] or a breast removal{{snd}}simple (total) mastectomy, radical mastectomy, modified radical mastectomy, skin-sparing mastectomy, and [[Nipple delay|subcutaneous (nipple sparing) mastectomy]]. The breast is reconstructed by first applying external tissue expansion to the recipient-site tissues ([[adipose]], [[gland]]ular) to create a breast-tissue matrix that can be injected with autologous fat grafts (adipocyte tissue); the reconstructed breast has a natural form, look, and feel, and is generally sensate throughout and in the nipple-areola complex (NAC).<ref name="Khouri RK 2010" /> The reconstruction of breasts with fat grafts requires a three-month treatment period{{snd}}begun after 3–5 weeks of external vacuum expansion of the recipient-site tissues. The autologous breast-filler fat is harvested by liposuction from the patient's body (buttocks, thighs, abdomen), is refined and then is injected (grafted) to the breast-tissue matrices (recipient sites), where the fat will thrive.

One method of non-implant breast reconstruction is initiated at the concluding steps of the breast cancer surgery, wherein the [[Oncology|oncological]] surgeon is joined by the reconstructive plastic surgeon, who immediately begins harvesting, refining, and seeding (injecting) fat grafts to the post-mastectomy recipient site. After that initial post-mastectomy fat-graft seeding in the operating room, the patient leaves hospital with a slight breast mound that has been seeded to become the foundation tissue matrix for the breast reconstruction. Then, after 3–5 weeks of continual external vacuum expansion of the breast mound (seeded recipient-site){{snd}}to promote the [[Histology|histologic]] regeneration of the extant tissues ([[adipose|fat]], [[gland]]ular) via increased blood circulation to the mastectomy scar (suture site){{snd}}the patient formally undergoes the first fat-grafting session for the reconstruction of her breasts. The external vacuum expansion of the breast mound created an adequate, [[Circulatory system|vascularised]], breast-tissue matrix to which the autologous fat is injected; and, per the patient, such reconstruction affords almost-normal sensation throughout the breast and the nipple-areola complex. Patient recovery from non-surgical fat graft breast reconstruction permits her to resume normal life activities at 3-days post-procedure.<ref name="Khouri RK 2010" />


====Tissue engineering====
=====The breast mound=====

The breast-tissue matrix consists of engineered tissues of complex, implanted, biocompatible scaffolds seeded with the appropriate cells. The ''in-situ'' creation of a tissue matrix in the breast mound is begun with the external vacuum expansion of the mastectomy defect tissues (recipient site), for subsequent seeding (injecting) with autologous fat grafts of adipocyte tissue. A 2010 study, reported that serial fat-grafting to a pre-expanded recipient site achieved (with a few 2-mm incisions and minimally invasive blunt-cannula injection procedures), a non-implant outcome equivalent to a surgical breast reconstruction by [[DIEP flap|autologous-flap]] procedure. Technically, the external vacuum expansion of the recipient-site tissues created a skin envelope as it stretched the mastectomy scar, and so generated a fertile breast-tissue matrix to which were injected large-volume fat grafts (150–600&nbsp;ml) to create a breast of natural form, look, and feel.<ref name="ReferenceC">Khouri RK, Cardoso E, Marchi A, Rigotti G. (2010) [https://www.miamibreastcenter.com/reconstruction/tissue-engineering-breast-autologous-fat-grafting Tissue Engineering a Breast Mound by External expansion & Autologous fat Grafting] {{Webarchive|url=https://web.archive.org/web/20150408081617/http://www.miamibreastcenter.com/reconstruction/tissue-engineering-breast-autologous-fat-grafting |date=2015-04-08 }}. miamibreastcenter.com</ref>

The fat graft breast reconstructions for 33 women (47 breasts, 14 irradiated), whose clinical statuses ranged from zero days to 30 years post-mastectomy, began with the pre-expansion of the breast mound (recipient site) with an external vacuum tissue-expander for 10 hours daily, for 10–30 days before the first grafting of autologous fat. The breast mound expansion was adequate when the mastectomy scar tissues stretched to create a 200–300&nbsp;ml recipient matrix (skin envelope), that received a fat-suspension volume of 150–600&nbsp;ml in each grafting session.<ref name="ReferenceC"/>

At one week post-procedure, the patients resumed using the external vacuum tissue-expander for 10 hours daily, until the next fat grafting session; 2–5 outpatient procedures, 6–16 weeks apart, were required until the plastic surgeon and the patient were satisfied with the volume, form, and feel of the reconstructed breasts. The follow-up mammogram and [[MRI]] examinations found neither defects (necrosis) nor abnormalities ([[Breast diseases|neoplasms]]). At six months post-procedure, the reconstructed breasts had a natural form, look, and feel, and the stable breast-volumes ranged 300–600&nbsp;ml per breast. The post-procedure mammographies indicated normal, fatty breasts with well-vascularized fat, and few, scattered, benign oil cysts. The occurred complications included [[pneumothorax]] and transient cysts.<ref name="ReferenceC"/>

=====Explantation deformity=====
The autologous fat graft replacement of breast implants (saline and silicone) resolves [[Complications (medical)|medical complications]] such as: [[capsular contracture]], implant shell rupture, filler leakage (silent rupture), device deflation, and silicone-induced [[granulomas]], which are medical conditions usually requiring re-operation and explantation (breast implant removal). The patient then has the option of surgical or non-implant breast corrections, either replacement of the explanted breast implants or fat-graft breast augmentation. Moreover, because fat-grafts are biologically sensitive, they cannot survive in the empty implantation pocket, instead, they are injected to and diffused within the breast-tissue matrix (recipient site), replacing approximately 50% of the volume of the removed implant{{snd}}as permanent breast augmentation. The outcome of the explantation correction is a bust of natural appearance; breasts of volume, form, and feel, that{{snd}}although approximately 50% smaller than the explanted breast size{{snd}}are larger than the original breast size, pre-procedure.

=====Breast augmentation=====

The outcome of a breast augmentation with fat-graft injections depends upon proper patient selection, preparation, and correct technique for recipient site expansion, and the harvesting, refining, and injecting of the autologous breast filler fat. Technical success follows the adequate external vacuum expansion of the recipient-site tissues (matrix) before the injection of large-volume grafts (220–650&nbsp;cc) of autologous fat to the breasts.<ref>{{cite web|url=http://www.thaimedicalvacation.com/cal-stem-cell-breast/ |title=Autologous cell enriched breast lipotransfer | access-date=2012-07-07}}</ref> After harvesting by liposuction, the breast-filler fat was obtained by low G-force syringe centrifugation of the harvested fat to separate it, by density, from the crystalloid component. The refined breast filler then was injected to the pre-expanded recipient site; post-procedure, the patient resumed continual vacuum expansion therapy upon the injected breast, until the next fat grafting session. The mean operating room (OR) time was 2-hours, and there occurred no incidences of [[infection]], cysts, [[seroma]], [[hematoma]], or tissue necrosis.<ref name="Del Vecchio D pp. 68">{{Cite journal | last1 = Del Vecchio | first1 = D. A. | last2 = Bucky | first2 = L. P. | s2cid = 205969440 | doi = 10.1097/PRS.0b013e3182050a64 | title = Breast Augmentation Using Preexpansion and Autologous Fat Transplantation: A Clinical Radiographic Study | journal = Plastic and Reconstructive Surgery | volume = 127 | issue = 6 | pages = 2441–2450 | year = 2011 | pmid = 21311393 }}</ref>

The breast-volume data reported in ''Breast Augmentation with Autologous Fat Grafting: A Clinical Radiological Study'' (2010) indicated a mean increase of 1.2 times the initial breast volume, at six months post-procedure. In a two-year period, 25 patients underwent breast augmentation by fat graft injection; at three weeks pre-procedure, before the fat grafting to the breast-tissue matrix (recipient site), the patients were photographed, and examined via intravenous contrast [[MRI]] or [[X-ray computed tomography|3-D volumetric imaging]], or both. The breast-filler fat was harvested by liposuction (abdomen, buttocks, thighs), and yielded fat-graft volumes of 220–650&nbsp;cm<sup>3</sup> per breast. At six months post-procedure, the follow-up treatment included photographs, intravenous contrast MRI or 3-D volumetric imaging, or both. Each woman had an increased breast volume of 250&nbsp;cm<sup>3</sup> per breast, a mean volume increase confirmed by quantitative MRI analysis. The mean increase in breast volume was 1.2 times the initial breast volume measurements; the statistical difference between the pre-procedure and the six-month post-procedure breast volumes was (P< 00.0000007); the percentage increase basis of the breast volume was 60–80% of the initial, pre-procedure breast volume.<ref name="Del Vecchio D pp. 68"/>