JOURNAL READING

The Use of Autologous Fat Grafts in Breast Surgery: A

Literature Review
Arranged to achieved some requirements in following clinical education program
section of surgery station

Arranged by :
M. Syihab Romzi. Z, S.Ked
15711068

Advisor :
dr. Mubarok Latief, Sp.B

FACULTY OF MEDICINE
ISLAMIC UNIVERSITY OF INDONESIA
CLINICAL OF SURGICAL DIVISION
RSUD DR. SOEDIRMAN KEBUMEN PROVINCE JAWA TENGAH
2019
 ANATOMY AND PHYSIOLOGY

A. DEFINITION
Breast
Breast is a hemispheric projection of variable size anterior to the pectoralis major
and serratus anterior muscles and attached to them by a layer of fascia composed of
dense irregular connective tissue.
Each breast has one pigmented projection, the nipple, that has a series of closely
spaced openings of ducts called lactiferous ducts, where milk emerges. The circular
pigmented area of skin surrounding the nipple is called the areola, it appears rough
because it contains modified sebaceous (oil) glands. Strands of connective tissue called
the suspensory ligaments of the breast (Cooper’s ligaments) run between the skin and
fascia and support the breast.
These ligaments become looser with age or with the excessive strain that can
occur in long-term jogging or high-impact aerobics. Wearing a supportive bra can slow
this process and help maintain the strength of the suspensory ligaments. Within each
breast is a mammary gland, a modified sudoriferous (sweat) gland that produces milk. A
mammary gland consists of 15 to 20 lobes, or compartments, separated by a variable
amount of adipose tissue. In each lobe are several smaller compartments called lobules,
composed of grapelike clusters of milk-secreting glands termed alveoli embedded in
connective tissue. Contraction of myoepithelial cells surrounding the alveoli helps
propel milk toward the nipples. When milk is being produced, it passes from the alveoli
into a series of secondary tubules and then into the mammary ducts. Near the nipple, the
mammary ducts expand to form sinuses called lactiferous sinuses, where some milk
may be stored before draining into a lactiferous duct. Each lactiferous duct typically
carries milk from one of the lobes to the exterior
B. ANATOMY

The breast mound

The mound of the adult female breast extends from the second rib above to the
sixth rib below. Medially, it borders the lateral edge of the body of the sternum, and
laterally it reaches the midaxillary line. At its superolateral extremity, the breast tissue
projects as a tongue into the axilla along the lower border of the pectoralis majordthe
axillary tail of Spence. The main bulk of the breast tissue is usually localized to its
upper outer quadrant. This quadrant is more often implicated in breast cancer and in
most benign lesions of breast tissue.

The nipple

The nipple is usually situated at the level of the fourth intercostal space in
nulliparous women, but its position is inconstant in relation to the intercostal space
when the breasts are pendulous. The 15e20 lactiferous ducts open on to the nipple. The
nipple itself is surrounded by the areola, which contains large sebaceous glands that are
often visible to the naked eyedthe glands of Montgomery.

Beneath the breast

On its deep aspect, about two-thirds of the breast lies on the pectoralis major.
Laterally, the breast overlaps on to the serratus anterior, and inferiorly it abuts on to the
upper part of the rectus sheath.

The fascial relationships of the breast are of practical importance. As an

ectodermal derivative, the gland lies in a pocket of superficial fascia. The superficial
layer lies immediately beneath the dermis and enables superficial flaps to be dissected
from the glandular mass of the breast quickly, neatly, and in a relatively avascular
plane. Moreover, dissection in this layer also ensures that breast tissue is not left
attached to the skin flaps.
 Fibrous processes of this layer of fascia extend to the skin and to the nipple and
are more developed over the upper part of the breast, where they form the suspensory
ligament of Cooper. Contraction of this tissue by malignant infiltration results in the
characteristic skin dimpling over a carcinoma of the breast.

The deep layer of the superficial fascia is thicker than the subcutaneous
component and covers the deep aspect of the breastplate Beneath this sheath is a layer
of filmy areolar tissue that allows the breast to move freely on the underlying fascial
covering of the pectoralis major and the serratus anterior. This areolar layer forms the
retromammary space. Deep infiltration of a cancer through this space into the
underlying pectoralis fascia produces the physical sign of deep tethering of a malignant
breast mass. Precise establishment of the plane of the retromammary space enables
rapid and relatively bloodless dissection of the deep aspect of the breast in simple
mastectomy.

Blood supply

The blood supply of the breast is a rich anastomotic network derived from the
axillary, internal thoracic (or internal mammary in the old nomenclature) and intercostal
arteries (Figure 2). The largest vessels arise from the internal thoracic artery, the
perforating branches of which pierce the chest wall adjacent to the sternal edge in the
first to fourth intercostal spaces. The vessel in the second space is usually the largest of
these. The four branches from the axillary artery are the superior thoracic, pectoral
branch of the acromiothoracic, lateral thoracic, subscapular. They are accompanied by
the corresponding veins.

Lymphatic drainage

The importance of lymphatic drainage of the breast and of the anatomy of the
axillary and internal thoracic lymph nodes is selfevident. The axillary lymph nodes vary
in number from 20 to 30 and are divided into five not wholly distinctive anatomical
groups.
 Efferents from the apical nodes unite into the subclavian trunk. On the left side,
this trunk usually drains directly into the thoracic duct. On the right side, the subclavian
trunk may empty directly into the jugulosubclavian junction or into a common right
lymphatic duct. A few efferent channels usually reach the inferior deep cervical nodes
directly. Clinicians and pathologists often define metastatic axillary node spread simply
into: level I: nodes inferior to pectoralis minor, level II: nodes behind pectoralis minor,
level III: nodes above pectoralis minor.

The internal thoracic (internal mammary) lymph nodes are small, often only 2e3
mm in diameter, and lie along the internal thoracic vessels 2e3 cm from the sternal
edge. Usually three to five of these nodes are found on either side. These nodes drain
the anterior chest wall, anterior portion of the diaphragm, upper portion of the rectus
sheath and muscle, and the superior portion of the liver, as well as the inner aspect of
the mammary gland. The intercostal nodes lie near the rib heads. They receive deep
lymph vessels from the posteromedial aspect of the chest and some drainage from the
lateral extremity of the mammary gland

About 75% of all lymphatic drainage of the breast passes to the axillary nodes.
The remainder principally drains to the internal thoracic nodes. Any part of the breast
may drain to either group, though there is a greater tendency for tumours situated in the
medial part of the breast to disseminate to the internal thoracic nodes than for tumours
in the lateral part of the breast to do so.

Involvement of the supraclavicular nodes in breast cancer usually represents

retrograde spread along blocked lymphatic channels when the apical axillary nodes are
heavily involved. Efferent channels pass directly from these nodes to the inferior deep
cervical chain so that involvement of cervical nodes may occur via this route.

Lymphatics do not normally drain to lymphatics across the opposite side of the
body; early lymphatic spread of a tumour from one breast to another does not occur.
Such bilateral cases represent synchronous or early metachronous double primary
tumours. In very advanced cases, extensive blockage of lymphatic channels allows
subcutaneous lymphatic permeation to occur to the opposite side
C. PHYSIOLOGY

Prior to puberty there are no discernible differences, functional or structural,

between the male and female breast. At the histological level, the prepubertal breast
both in males and in females, consists of multiple rudimentary ducts arranged
circumferentially, and converging towards the nipple. At the blind end of each
rudimentary duct are poorly-developed but potentially secretory acini.
With the onset of puberty, a striking sexual dimorphism becomes manifest as
dramatic changes ensue in the morphology and function of the female breast. These
changes are the result of the unique response of the breast to various normal hormonal
influences. The following account of breast physiology pertains exclusively to the
female breast.
The prime function of the female breast is lactation: a term that encompasses
synthesis, secretion and ejection of milk. Additionally the female breast is a prominent
secondary sexual feature. The initial growth of the female breast at puberty is affected
primarily by oestrogen (oestradiol) which induces proliferation and branching of the
duct system and also maturation and prominence of the nipples. However, the
development and proliferation of acini (alveoli) at the areolar ends of the ducts is the
result of the combined and synergistic actions of oestrogen and progesterone. Within the
breast tissue there are a number of paracrine factors, some stimulatory and some
inhibitory, which influence cell division and differentiation. These paracrine regulators
include insulin-like growth factors, epidermal growth factor and transforming growth
factor b.

Lactation
The endocrine regulation of milk synthesis is complex. After initial conditioning
of the mammary secretory tissue by oestrogen and progesterone, there is a specific need
for lactogenic hormone alongside the permissive actions of glucocorticoids, insulin and
thyroxine for successful milk production.
 There are two lactogenic hormones: (i) prolactin which is secreted by the
lactotrophs in the anterior pituitary and (ii) human placental lactogen (hpL) which is
produced by the maternal placenta. The secretion of the latter reaches a peak during the
final weeks of gestation and this prepares the breast for milk production. At this stage
there is no significant secretion of milk because the high levels of oestrogen and
progesterone in maternal blood have an inhibitory effect on milk production. Soon after
childbirth, hpL disappears from the maternal circulation, the levels of oestrogen and
progesterone in maternal blood plummet and prolactin functions as the sole lactogenic
hormone. Another hormone which plays an important role in lactation is oxytocin, a
polypeptide which is synthesized in the hypothalamus and stored in the posterior
pituitary (neurohypophysis). The act of nursing (the sucking reflex) stimulates the
release of oxytocin which in turn mediates the secretion of prolactin.
The normal, healthy, well-nourished lactating woman forms about 1 litre of milk a
day. Lactation can be artificially suppressed by the administration of oestrogen or by
administering dopaminergic agents such as bromocriptine which have an inhibitory
effect on the synthesis and release of prolactin.

Menopausal changes
The onset of menopause is associated with a natural and steep decline in the
body’s production of oestrogen and progesterone. This lack of hormonal stimulation
results in a progressive decrease in the amount of glandular tissue in the breast, and a
concomitant increase in fatty tissue. The consequent reduction in tissue density renders
the breast tissue more amenable to mammographic examination. It is for this reason that
detection of neoplasms by mammography is easier in a menopausal or perimenopausal
woman than in a young, premenopausal woman.
 SUMMARY OF JOURNAL
The use of autologous fat grafts in breast surgery: A literature review

Introduction
Autologous fat transfer was first performed by Neubauer in 1893 for the repair of
facial defects. Theoretically, autologous fat grafts may constitute an ideal source for the
repair of congenital, developmental or acquired soft tissue defects. They have multiple
advantages in comparison with other filling materials and implants; they are
biocompatible, cost-effective and can be obtained from several donor sites in the human
body that are suitable for fat harvesting. Additionally, fat grafting procedures can be
repeated at certain time intervals. Moreover, the lipo-contouring of the donor site may
be perceived as a cosmetic advantage, which makes the procedure appealing for
patients. Despite these advantages, the greatest disadvantage limiting the use of fat
grafts is the unpredictability of the final outcome and the dependence of graft volume on
fat retention and growth.
Breast cancer is the most common malignancy in women, accounting for
approximately 30% of malignancies in women. Fat grafts have a long history of use in
breast surgery for reconstructive purposes. Nonetheless, many unanswered questions
remain regarding the use of fat grafts (Table 1). This literature review aims to focus on
the use of fat grafts in breast surgery, which has recently expanded in popularity.

Table 1. Pending questions to be answered about fat grafts

Survival of fat grafts

1. How can we predict the survival rate of fat grafts?
2. Does the choice of the donor area affect the survival of the graft?
3. Which technique should be used to harvest the graft?
4. How should the graft be prepared in order to achieve maximum graft survival?
5. Which is the best injection technique?
6. Do adipose stem cells carry hope for the future?

Oncological safety of fat grafts

1. Does fat grafting increase the risk of breast cancer?
2. Do fat grafts mask malignant lesions radiologically?
3. Should patients who have undergone fat grafting be offered a follow-up procedure
 different from the normal population?
4. If a suspicious lesion is detected in a breast that has undergone fat grafting, how
should the lesion be evaluated?
5. Is there any way to distinguish microcalcifications from breast cancer on
mammography?
6. Which radiological methods are most suitable for follow-up?

Use of Fat Grafts in Breasts

Today, fat grafts are used for the cosmetic augmentation of hypoplastic breasts, in
congenital anomalies (tuberous breasts and Poland syndrome) and in reconstructions
due to breast cancer. The results strongly depend on the technique and the experience of
the surgeon. In literature, graft loss rates have been reported to range between 20% and
90% over a 1-year time period. Although advanced techniques used in fat transfer have
led to improved results, there are still no standardized methods for fat harvesting,
preparation and injection into the recipient site. In order to increase the survival rate of
fat grafts, various modifications have been planned for every step. The most prominent
modifications are cell-assisted lipotransfer (CAL).
There are two oncological problems concerning fat grafts applied to the breast.
First, since the fat undergoes varying levels of nodule formation and calcifications, it
may be confused with breast cancer on a physical examination and radiological imaging
and thereby hinder an early diagnosis of breast cancer. Second, fat grafts may
themselves produce local oestrogen in stromal-epithelial interactions either by means of
aromatase originating from the adipocytes or through mediators known as adipokines,
thereby facilitating the development of breast cancer.

Influence of Endocrine and Paracrine Pathways on the Adipose Tissue

Microenvironment
Autologous fat is inherently distinct from other filling materials and silicone
implants for several reasons. First, the transferred fat is actually viable tissue, with the
potential to influence the microenvironment of the transplant site through paracrine and
endocrine pathways. Initially, adipocytes were considered as cells that only stored
energy, but within the last 10 years, it has been discovered that they act as endocrine
cells by synthesising molecules known as adipokines. Adipokines are a heterogeneous
group that includes hormones, growth factors, chemokines and pro-inflammatory
molecules. Numerous experimental studies have demonstrated that adipocytes support
cancer formation, invasion, migration and resistance to treatment through various
paracrine and endocrine pathways. A chronological comparison of some of these
experimental studies is presented in Table 2.
Following important features of adipose tissue must be clarified to understand the
usability of fat grafts in breast surgery: (1) The structure and content of adipose tissue in
the human body; (2) The isolation of adipose-derived stromal/stem cells (ADSCs); or
(3) The oncological safety of autologous fat transfer to breast.

1. The structure and content of adipose tissue in the human body

Mammals have two different types of adipocytes (white and brown). There is also
a third type of beige (brown/white) adipocyte that is closely linked to white adipocytes.
white fat serves for energy storage and is involved with gaining and losing weight,
while the main purpose of brown fat is thermoregulation. Later studies have revealed
that fat tissue is not as insignificant as imagined; instead, it is rather important because
fat storage and metabolism are regulated by neural and endocrine factors. White fat
tissue consists not only of fat-storing adipocytes, but also a considerable amount of
supporting cells surrounding the adipocytes. This heterogeneous cell group is called the
stromal vascular fraction (SVF). The SVF is composed of ADSCs, vascular endothelial
cells and their precursors, lymphocytes, macrophages and fibroblasts.
Traditionally, two major fat storage areas have been recognized: visceral fat tissue
and subcutaneous fat tissue. Obesity is also an independent negative prognostic factor
for breast cancer, although no direct link between obesity and breast cancer has yet been
established. However, obesity can affect breast cancer risk in different manners. Obesity
alters the cellular composition of adipose tissue by influencing the T-lymphocyte
concentration of adipose depots. In obesity, the production of a number of
inflammation-related adipokines is increased within adipose tissue. The only exception
to this trend is adiponectin, the production of which is decreased. Regenerative
macrophages contribute to the formation of new preadipocytes with the help of existing
adipocytes in a process known as neoadipogenesis, which is an important step for fat
graft survival.

2. Isolation of ADSCs
A ground-breaking study on human fat tissue was published by Zuk et al. in 2001,
demonstrating that stem cells could be isolated from human tissue and could
differentiate into adipogenic, chondrogenic, myogenic and osteogenic cells. Subsequent
studies have shown that ADSCs can also transdifferentiate into various other types of
cells. ADSCs can be obtained easily and abundantly through liposuction or the excision
of fat tissue.
When it comes to the application of fat grafts in breast surgery, ADSCs have been
increasingly used in combination with fat grafts in recent years with the hope of
improving the durability of fat grafts. Inadequate neovascularization is not the only
factor leading to the loss of grafted fat tissue. Mechanical damage and membrane
damage to the cells and mechanisms such as apoptosis are also contributing factors.

3. The oncological safety of autologous fat transfer to the breast

Although has several advantages, oncological safety is still a major issue that
limits its use in breast reconstruction. The main concern about safety is that ADSCs
may secrete growth factors that increase the possibility of breast cancer recurrence.
There are considerable differences in terms of oncological safety. First, when a fat
graft is used for breast reconstruction, the injection is made into a high-risk area for
cancer development in a patient with established familial, genetic and cellular risk
factors. Second, the importance of postoperative follow-up varies between these patient
groups. Third, there are discrepancies in the literature between clinical and experimental
studies of the oncological safety of fat grafting. Several reasons for this discrepancy
may exist, as follows: (1) There are differences between the experimental animals and
humans in terms of the cells constituting the breast tissue. (2) When fat grafts are
transferred to the breast, they do not only contain adipocytes, but also other cells within
the SVF. (3) When fat grafts are injected into the breast, the graft material is transferred
to areas where fat tissue already exists.
Clinical studies
Autologous fat grafting in breast surgery seems to be clinically safe, but
experimental studies have shown that fat grafting may increase the likelihood of
recurrence. Several researchers agree that fat transfer into the breast is a reliable
method. However, it should be noted that studies on patient groups where lipofilling has
been performed for the purposes of breast augmentation are based mainly on the
authors’ opinions, due to the inadequate patient number and short duration of follow-up.
In 2013, Petit et al. indicated that fat injection is a oncologically reliable method even in
patients with breast cancer. Nevertheless, they pointed out that fat injections may
present a risk in patients with intraepithelial neoplasia. Gale et al. found no significant
difference in the cancer recurrence rate compared with the control group. Petit et al.
published another clinical study in 2017 and did not observe any difference in the
incidence of recurrent breast cancer (local recurrence, axillary node metastasis or distant
metastases). Myckatyn et al. found an equivalent risk of cancer recurrence in
comparison with those who did not undergo a fat grafting procedure. Silva-Vergara et
al. also found similar results. Kronowitz et al. suggested that hormonal therapy
contributes to a tumor-forming environment between ADSCs and breast cancer cells.
From an oncological standpoint, we are presently unable to state that autologous fat
grafting is a safe method. However, we can claim that there is no clear clinical evidence
that fat grafting in breast reconstruction increases the risk of breast cancer.

Experimental studies
ADSCs can be easily harvested from white adipose tissue and they have multiple
functions, including immunomodulation, antiapoptosis, angiogenesis and regeneration.
Because of these properties, ADSCs have been frequently thought to promote breast
cancer development. Nevertheless, other studies have shown that ADSCs may inhibit
the growth of breast cancer. Yu et al. reported that human adipocyte stem cells
enhanced in vivo tumor growth when injected into an animal model. Walter et al. also
showed that interleukin-6 secreted by ADSCs plays an important role in the invasion
and migration of breast cancer cells. Martin-Padura et al. demonstrated that co-injection
of human fat graft and CD34+ cells significantly increased tumor growth and
metastases in breast cancer models. Kamat et al. also showed that adipose-derived
mesenchymal stromal cells have the potential to promote tumor progression in an in
vitro study of breast cancer cells. Molto-Garcia et al. demonstrated that autologous fat
graft did not worsen the prognosis of breast cancer when used in the same way as is
done routinely in clinical practice. In light of the studies mentioned above, we cannot
conclude that the experimental studies have provided definitive results.

Radiological Follow-Up After Fat Grafting

An important question regarding radiological changes is whether only fat grafting
leads to radiological changes which may be confused with cancer, or whether other
widely accepted surgical modalities such as breast reduction cause similar changes.
Another question relates to the method of radiological follow-up. It is very
challenging to differentiate between benign and malignant lesions of the breast
radiologically, and there are on-going studies focusing on this point. Three imaging
methods are the main focus of these studies: mammography, USG and MRI. even
though fat injection was not proven to increase the risk of breast cancer, it may cause
radiological confusion during the follow-up period. Radiological and clinical
monitoring of the breast must be performed after all surgical interventions applied to the
breast. Although mammography is preferred by radiologists as a technique to
distinguish between benign and malignant lesions, suspicious lesions should be re-
evaluated using USG and MRI. If suspicion remains, a biopsy must be performed
without delay.

Conclusion
Patients who undergo breast augmentation with a fat graft for aesthetic purposes
are not at an elevated risk for future breast cancer development. Other surgical
procedures performed in the breast can also lead to radiological images that can be
confused with breast cancer. In light of ongoing studies, the prediction that fat grafts
will replace breast implants in the future is gaining greater traction. Although numerous
experimental and clinical studies have investigated fat graft reliability, there is still no
clear consensus on the oncological safety of fat grafting. Controlled postoperative
studies with longer follow-up periods are needed in order to shed light on this issue.
JOURNAL CRITICAL APPRAISAL

Journal Identity
Title : The use of autologous fat grafts in breast surgery: A literature review
Author : Yalcin Bayram , Melihcan Sezgic , Percin Karakol , Mehmet Bozkurt ,
Gaye Taylan Filinte
Journal : The Korean Society of Plastic and Reconstructive Surgeons
Year : 18 October 2019

PICO
Item Answer
Patient / Problem Breast
Intervention Surgery, Mammaplasty
Comparison -
Outcome Evaluate reliability of the treatment
 CASP Critical Appraisal Checklist for Systematic Review

Question Yes No Ket

‐ Yes, the purpose of the study has been written

1. Did the review in the abstract and introduction.
address a
√
clearly focused
question?

2. Did the authors ‐ Yes, Review article is the right type of paper
look for the
√ to describe the issue.
right type of
papers?

3. Do you think ‐ Yes, important and relevant studies were

all the
included this article.
important, √
relevant studies
were included?

4. Did the ‐ Author in this article could explain about the

review’s
authors do content of the article but doesn’t mentioned
enough to √ about assessing the quality of the studies
assess quality
of the included
studies?

‐ No, both of group weren’t always similar.

5. If the results of
the review have
been combined,
√
was it
reasonable to
do so?
 ‐ Yes. “Patients who undergo breast
6. What are the augmentation with a fat graft for aesthetic
overall results
of the review? √ purposes are not at an elevated risk for
future breast cancer development”.

Yes. “Fat grafting in breast surgery is a

7. How precise
are the results? √ powerful tool for correcting asymmetries, and
is also known to be a safe procedure”.
8. Can the results ‐ Yes it could be applied in local population.
be applied to
the local √
population?

9. Were all ‐ Yes. “Controlled postoperative studies with

important
outcomes √ longer follow-up periods are needed in order
 considered? to shed light the issue”.

‐ Yes. “Although numerous experimental and

10. Are the benefits √
worth the clinical studies have investigated fat graft
harms and reliability, there is still no clear consensus on
costs?
the oncological safety of fat grafting”.
 Reference
1. Neuber F. Fettransplantation. Chir Kongr Verhandl Dsch Gesellch Chir 1893;22:66.
2. Chan CW, McCulley SJ, Macmillan RD. Autologous fat transfer: a review of the literature with a
focus on breast cancer surgery. J Plast Reconstr Aesthet Surg 2008;61: 1438-48.
3. Trojahn Kolle SF, Oliveri RS, Glovinski PV, et al. Importance of mesenchymal stem cells in
autologous fat grafting: a systematic review of existing studies. J Plast Surg Hand Surg 2012;46:59-68.
4. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose
autotransplants. Aesthetic Plast Surg 1994;18:17-9.
5. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2019. CA Cancer J Clin 2019;69:7-34.
6. Czerny A. Plastischer Ersatz der Brustdruse durch ein Lipoma. Chir Kongr Verhandl 1895;216:2.
7. Report on autologous fat transplantation. ASPRS Ad-Hoc Committee on New Procedures,
September 30, 1987. Plast Surg Nurs 1987;7:140-1.
8. Khouri RK, Eisenmann-Klein M, Cardoso E, et al. Brava and autologous fat transfer is a safe and
effective breast augmentation alternative: results of a 6-year, 81-patient, prospective multicenter study.
Plast Reconstr Surg 2012;129: 1173-87.
9. Gutowski KA; ASPS Fat Graft Task Force. Current applications and safety of autologous fat
grafts: a report of the ASPS fat graft task force. Plast Reconstr Surg 2009;124: 272-80.
10. Rubin JP, Coon D, Zuley M, et al. Mammographic changes after fat transfer to the breast
compared with changes after breast reduction: a blinded study. Plast Reconstr Surg 2012; 506 129:1029-
38.
11. Bernard RW, Beran SJ. Autologous fat graft in nipple reconstruction. Plast Reconstr Surg
2003;112:964-8.
12. Chajchir A, Benzaquen I. Liposuction fat grafts in face wrinkles and hemifacial atrophy.
Aesthetic Plast Surg 1986; 10:115-7.
13. Wang G, Ren Y, Cao W, et al. Liposculpture and fat grafting for aesthetic correction of the
gluteal concave deformity associated with multiple intragluteal injection of penicillin in childhood.
Aesthetic Plast Surg 2013;37:39-45.
14. Rusciani Scorza A, Rusciani Scorza L, Troccola A, et al. Autologous fat transfer for face
rejuvenation with tumescent technique fat harvesting and saline washing: a report of 215 cases.
Dermatology 2012;224:244-50.
15. Yoshimura K, Sato K, Aoi N, et al. Cell-assisted lipotransfer for cosmetic breast augmentation:
supportive use of adipose-derived stem/stromal cells. Aesthetic Plast Surg 2008; 32:48-55.
 16. Zheng DN, Li QF, Lei H, et al. Autologous fat grafting to the breast for cosmetic enhancement:
experience in 66 patients with long-term follow up. J Plast Reconstr Aesthet Surg 2008;61:792-8.
17. Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr
Surg 2007;119:77585.
18. Zocchi ML, Zuliani F. Bicompartmental breast lipostructuring. Aesthetic Plast Surg 2008;32:313-
28.