Breast augmentation by autologous fat transfer (Lipoaugmentation)

A relatively new method of breast enlargement is with autologous adipose tissue (lipoaugmentation). This method has been developed and practiced by some plastic surgeons for over a decade. Nevertheless, it has only recently been approved as being safe and reliable under certain conditions by several national plastic surgery associations (ASPS, SOFCPRE, Swiss Plastic Surgery).
In addition to increasing breast size, autologous fat is injected to restore or shape the breast (lipomodeling). In both cases, autologous fat injection serves the purpose to avoid the use of foreign material (breast implants) and to prevent visible scars as far as possible. Autologous fat transfer to the breast is currently being further developed, refined and tested, and is thus not yet regarded as a standard procedure. However, there is encouraging evidence and has been intense scientific effort to establish a standardised technique for autologous fat injection in breast surgery.
Breast enlargement and shaping by autologous fat tissue (lipoaugmentation/lipomodeling) involves the removal of fat from areas of the body with excess fat deposits, preparation of adipose tissue by various methods (e.g. sedimentation, centrifugation) and injecting the treated fat into the breast tissue with fine needles. Repeated treatments may be useful in order to achieve an optimal result.

Considerations

When to consider breast augmentation with autologous fat tissue:

• You feel your breasts are too small (hypoplasia)
• You feel uncomfortable in swimwear or tight-fitting tops because of your breast size.
• Your breasts have lost their former volume and firmness after pregnancy and/or breastfeeding (involution atrophy)
• Your breasts have become smaller and have lost their elasticity over time.
• Your breasts are too small or sag down due to weight loss.
• One breast is noticeably smaller than the other (asymmetry).
• One or both breasts are abnormally shaped and too small.

Also, women may benefit from lipomodeling of the breast under the following conditions.

• You have lost a breast due to breast cancer.
• You have problems with silicone implants after a breast augmentation: repeated encapsulation of breast implants, palpable or visible implant edges.
• You have problems after irradiation of the breast: wound complications, scarring (fibrosis), or deformation of breast shape.
• You have problems after a breast reconstruction with silicone implants or with your own tissue (flap surgery): breast asymmetry or deformity.
• You suffer from a congenital breast anomaly: tubular breasts (congenital malformation), Poland syndrome (congenital absence of breast), pectus excavatum (congenital malformation of the chest wall with a funnel-shaped depression of the sternum).

Women who are considering a breast augmentation with autologous fat should preferably be healthy. Any bleeding disorder or tendency of increased swelling must be communicated to the surgeon prior to treatment in order to weigh up the risks versus benefits of having autologous fat injections. The decision to have a breast augmentation with autologous fat depends on the individual anatomy and proportions and the specific aims of the patient.

Women opt to have a breast augmentation for various reasons. Many women who previously had normal breasts suffer from a loss of volume (involution atrophy) and elasticity after pregnancy and breastfeeding and would like to regain firmer breasts or to recover their former breast size and shape. The natural aging process or weight loss can lead to similar changes in the breast, such as atrophy and sagging. Some women may simple find their breasts too small or underdeveloped (mammary hypoplasia). The breast shape and size may differ between sides (asymmetry). Various congenital or acquired breast deformities can be corrected with autologous fat injections.

Although having small or sagging breasts does not usually lead to physical discomfort, it can however cause significant psychological problems and reduced self-esteem, thus adversely affecting personal and professional life, as well as sexuality. In such cases a breast augmentation can improve wellbeing and self-esteem.

Whilst in the past, the correction of irregular contours or dimples following liposuction were at the forefront of treatment with autologous fat, the range of applications has now extended to a variety of problems in the breast area.

• Complications that can occur after breast augmentation or a breast reconstruction with silicone implants, can be partially treated by the injection of the patient’s own fat tissue.
• Visible or palpable implant edges or undulations (so-called ‘rippling’) can be corrected by the injection of fat tissue.
• In cases of severe capsular contracture (strong reaction around an implant with painful scarring and deformation of the breast), the implant can be removed and the missing volume replaced by the body’s own fat tissue.
• For small breasts, a moderate breast augmentation can also be undertaken by autologous fat injection, avoiding the insertion of breast implants.
• In selected cases, breast reconstruction can be performed by autologous fat injection following partial or total removal of the breast due to breast cancer.
• For women with large breasts, however, several treatments are usually necessary in order to achieve the desired or symmetrical breast volume.
• • Due to individual differences in degradation of fat cells after injection (30–70%), the treatment per recoverable breast volume and therefore the exact number of treatments required in individual cases is difficult to predict.
• 1–2 sessions are usually required for a moderate breast enlargement, while 4 or more sessions are needed for a breast reconstruction.
• For the correction of congenital breast deformities (malformed or asymmetrical breasts), normal and symmetric breast shape can be produced by the autologous fat injections alone, or in combination with breast implants or breast lift operations.
• The positive effects of injecting the patient’s own fat to aid blood circulation and wound healing to treat skin lesions or scars after accidents or breast irradiation.

The possible applications of autologous fat injection in the breast are rapidly developing. Due to the widely varying results depending on the respective treatment techniques and individual patient factors, lipofilling of the breast is currently not a standard procedure and is therefore only recommended in selected cases.

Consultation

A prerequisite to a successful operation is careful planning. This starts with a personal consultation at the AARE KLINIK.

• Communication of wishes and expectations ascertain what you would like to improve.
• Explanation of the possibilities and scope of the operation.

Examination:

• Medical history is taken.
• Physical examination is performed.
• Digital photos are taken.
• Desired breast size and shape are discussed, as well as the position and size of the nipples.
• Pre-existing asymmetry in the breasts or chest, skin quality and existing scars are ascertained.
• The availability of sufficient fat deposits elsewhere on the body (donor areas) is essential for the lipoaugmentation.
• Ideally the volume of fat deposits should be sufficient for a repeat of the procedure.
• Individual factors and personal wishes help in jointly deciding the right breast size and choice of appropriate surgical technique, the position of incisions and resulting scars.
• Based on this, an individual treatment plan is drawn up and goals of the operation are discussed and defined.
• Risks and possible complications are discussed and documented.

To plan the operation and to make a risk assessment we require:

• Full medical history (pre-existing conditions and previous surgery).
• Current diseases (high blood pressure, diabetes, thyroid dysfunction).
• Allergies or aversion to medications.
• Any important medical reports.
• Important medical information (in particular anything relating to your breasts, e.g. mammography).
• Inform the surgeon if you have a history of breast cancer in your family.
• Inform the surgeon of any diseases or previous surgery in the thoracic area (e.g. breast biopsy).
• If you are planning to lose a significant amount of weight or to get pregnant, this should be considered when planning a breast augmentation as the size of your breasts can alter unpredictably through weight fluctuation, pregnancy or breastfeeding.

There is no scientifically based evidence that a breast augmentation interferes with pregnancy or the ability to breastfeed. However, the long-term result of breast augmentation might be affected by pregnancy. It may be advisable to wait for the stabilisation of your weight or until after pregnancy/breast feeding before surgery is undertaken.
Depending on your age, personal and familial risk factors, it may be advisable to have a mammography, breast ultrasound or MRI (magnetic resonance imaging) before having a breast augmentation. Currently there is no scientifically based evidence to indicate that breast augmentation with autologous fat increases the risk of developing breast cancer.
Autologous fat injections can, however, result in calcium deposits in the breast tissue, which are visible on mammograms and can render the detection of a breast cancer more difficult. Additional studies of the breast with ultrasound or magnetic resonance imaging may be required to further clarify the suspicion of breast cancer after an autologous fat injection.
The exact impact of the various components of injected fat (fat cells/adipocytes, fat precursor cells/preadipocytes, connective tissue, blood cells, stem cells, growth factors, etc.) on the breast tissue in individuals is not known. Thus, a lipoaugmentation in women with an increased risk of breast cancer is currently not recommended.

Procedure

• First, fat is obtained from other parts of the body where there is an excess of fat (e.g. tummy, hips, thighs).
• The fat is acquired under sterile conditions using liposuction with special needles and a slight negative pressure in order not to damage the fat cells.
• Subsequently, the adipose tissue obtained for injection is prepared.
• The fat tissue is cleaned using various methods to remove blood and tissue components.
• The result is a largely homogeneous gel composed of fine fat droplets that can be injected with fine needles into the breast.
• The autologous fat injection is carried out exclusively in the subcutaneous fatty tissue and chest muscles, but not into the mammary gland itself.
• This is so that benign (macro-) calcifications in the breast resulting from autologous fat injections can easily be distinguished from malignant micro-calcifications resulting from breast cancer.
• The fat droplets are injected with fine needles and distributed evenly through many passages within the target tissues (subcutaneous fat and muscle) to ensure optimum healing.
• After the injections, the breast can be shaped by light massage.
• Finally, bandages or a special bra are applied to the breast.

Breast augmentation with autologous fat (lLipoaugmentation) is ususally performed under general anaesthesia as an outpatient procedure at the AARE KLINIK or as part of a short hospital stay. The surgery usually takes 4–5 hours.

Risks

Breast augmentations are among the most common surgeries performed by plastic surgeons. However, the results of lipoaugmentation are less consistent than those of breast augmentation using implants due to the inconsistent take rate of fat cells, which the surgeon cannot fully control. With proper indications and conduct, serious complications are very rare. In individual cases, however you may require additional treatment.

Lighter complications that usually heal without consequences include bruising (hematoma), wound fluid accumulation (seroma) and swelling. Severe hematoma or seroma may necessitate surgical removal.
Reduced sensation of the breast skin and nipples are common, but usually only temporary. Swelling and bruising are the most common side effects of an autologous fat injection breast and usually subside within 2–3 weeks. Slight asymmetries or uneven contours usually correct spontaneously with a decrease in swelling.

Due to partial resorption of the injected adipose tissue (30–70%), the desired breast volume may not result and further treatments may be need to reach the final goal. The degradation of injected fat cells may lead to oily deposits (oil cysts) in the breast that are partially absorbed by the body, but occasionally have to be removed by needle aspiration when they are large, palpable or discomforting. Furthermore, dead fat cells can cause fine calcium deposits in the tissue. These benign calcifications can usually be distinguished from malignant microcalcifications of breast cancer by experienced radiologists. However, it ought to be known that the detection of breast cancer can be difficult when there are pronounced calcifications in breast tissue. In this case, along with a mammography, breast ultrasound (sonography) and magnetic resonance imaging (MRI) can be helpful.
Infection is a rare but serious complication that then usually results in a loss of the injected fat tissue and can cause scarring. Uneven contours, depressions – so-called “dents”– may require surgical correction.

Overall, a lipoaugmentation is a safe procedure when undertaken by an experienced plastic surgeon and patients are mostly satisfied with the results. You can help to minimise the risks by following the advice of your surgeon. Every patient should be informed of all the benefits, risks and possible complications involved.

General risks

• Haematoma (bruising), bleeding and swelling
• Seroma (accumulation of wound secretion)
• Fat necrosis (oil cysts)
• Volume loss by fat resorption (undercorrection)
• Healing problems or infection
• Numbness in area of operation (temporary or permanent)
• Circulatory problem of breast skin or nipple
• Scars
• Slight asymmetry
• Secondary surgery
• Thrombosis or embolism

Preparation

Our aim is to make the time before and after your surgery as comfortable as possible. By following a few tips you can support our care:

• To aid the healing process, avoid smoking for two weeks before and after the operation.
• Avoid medication that increases the risk of bleeding, like aspirin, non-steroidal anti-inflammatory drugs, as well as vitamins and homeopathic remedies for two weeks prior to the operation.
• As this is a relatively new treatment, it is recommended to have a mammography or sonography and possibly also an MRI scan before and after having lipoaugmentation to rule out any pre-existing changes in the breast and to aid the detection and assessment of future changes in the breast tissue.
• It is still possible to perform a self-assessment, mammography, ultrasound and magnetic resonance imaging after a lipoaugmentation.
• Breast augmentations with autologous fat injection are mostly performed as an outpatient procedure under general anaesthesia.
• Make sure that you can be collected and cared for by someone for 24 hours after the procedure.
• In some cases, it may be recommended to stay overnight as an inpatient in hospital.

Day of surgery

In most cases, lipoaugmentation surgery is an outpatient procedure under general anaesthesia that can be performed at the AARE KLINIK. In individual cases, when necessary, the procedure can be undertaken in an affiliated private hospital.

• During surgery you will receive various medications for your wellbeing.
• Usually breast augmentations are performed under general anaesthesia.
• For your safety, your heart rate, blood pressure, oxygen supply etc. are monitored during the operation.
• After surgery a special bandage or bra is applied.
• You will be taken to the recovery room, where you will have continued monitoring until you awaken and are able to get up.
• You will be allowed to return home after a few hours.
• If you are an inpatient, you will remain in the recovery ward until the following day.
• Already on the day of the surgery, you should get up regularly for a few minutes in order to minimise the risk of thrombosis.
• The level of pain after a breast augmentation is not severe and can be compared with muscular pain.
• You can use mild pain relief that reduces swelling. You can continue taking this during the first few days after surgery.
• You should have someone to care for you continuously for 24 hours after surgery.
• We also offer the possibility for a short inpatient stay at the AARE KLINIK in a single room with a private nurse if required.

After surgery

• It is important to realise that recovery from an operation varies for every individual.
• Do not raise your arms above the level of the shoulders or move them excessively and do not lift heavy objects.
• As a rule, you should sleep on your back for several weeks after surgery.
• Only take the prescribed painkillers and avoid any medication that contains aspirin or other blood-thinning substances.
• Wear the special bra and adjust it continuously over a total period of 4–6 weeks as per our recommendations.
• Wear the compression garments (hosiery) to reduce swelling in the areas where fat tissue was removed by liposuction.
• Physically demanding and sporting activities should be avoided for several weeks.
• In the first 2–5 days after the procedure, a feeling of tension and light pain will be felt in the region of the surgery.
• Breast skin and nipples may temporarily feel numb or hypersensitive.
• Slight swelling and bruising in the area of the breast usually subsides within 4–6 weeks. The same applies to the areas in which liposuction was performed.
• Typically you will be back on your feet a couple of days after surgery and be able to resume your daily activities.
• Bandages are removed in the first days after the operation, after which you can take showers again.
• Full baths and excessive heat (e.g. sauna), however should be avoided for several weeks until swelling has receded.
• A few stitches may have to be removed after one week.
• You will probably be able to start work again one week after surgery.
• After surgery you will be examined at the AARE KLINIK at regular intervals, so that the healing process can be assessed until the final result is achieved.

Outcome

• The healing process is gradual and it takes several months before the final result can be determined conclusively.
• The tiny scars on the breast and areas from where fat was removed might be a bit red for several months or appear pigmented, but this will fade with time until the scars and are barely visible.
• Scars are easy to conceal, even when wearing revealing clothing.
• A breast augmentation makes the breasts appear fuller and firmer and improves their shape.
• After breast augmentation, women often feel more self-confident and find it easier to wear certain clothes.
• A positive side effect of lipoaugmentation is the removal of excess fat elsewhere on the body.
• The result of a breast augmentation with autologous fat is usually long lasting. However, due to the initial swelling followed by a partial resorption of fat cells, the breast volume reduces over time in the first 2–3 months. Only then can the full effects of the procedure be assessed.
• Gravity and the aging process continue to affect the breasts of every woman, gradually changing their shape and size over time.
• Weight fluctuations, pregnancy and lifestyle can also affect the outcome.
• If you are unhappy with the shape of your breasts after a few years, another lipoaugmentation or a breast lift can be performed.

Costs

• A lipoaugmentation is generally a purely aesthetic procedure and therefore the patient, herself, has to carry the cost.
• Rare exceptions where a breast augmentation is medically indicated are: serious malformations of the breast, e.g. congenital absence of one or both breasts (amastia), or severe breast asymmetry. In these cases, the costs of a lipoaugmentation may be covered by the health insurance.
• However, in these cases there is no automatic obligation of the health insurance to cover the costs. Thus, a request for reimbursement of the costs must be made before the procedure.
• The decision as to whether a lipoaugmentation is regarded as being medically necessary is decided by the medical officer in each individual case.

The costs of an aesthetically indexed lipoaugmentation are variable and mainly depend on the complexity of the operation and the facility in which the surgery is performed (hospital or AARE KLINIK). A more accurate cost estimate can therefore be made only after a personal consultation.

The costs are composed of:

• Operation fee (incl. preliminary and follow-up)
• Anesthesia fees
• Technical costs (AARE KLINIK/hospital)
• Inpatient hospital costs
• Special bra
• Medication
• Diagnostics (laboratory, ECG, etc.)

Appointment for breast-augmentation with Dr. Scheufler in Bern

Before any breast surgery you should have a comprehensive consultation and additional examination. Only in this way can you be sure whether the type of surgery will lead to the result you expect. In addition, your consultation will give you a good impression of our experience in the field of breast surgery. Feel free to ask for before and after photos to get an idea of what the results look like.

PD Dr. Oliver Scheufler, board certified plastic, reconstructive and aesthetic surgeon and author of this website, is pleased to be at your service for a personal consultation. Besides his main occupation at the AARE KLINIK, Dr. Scheufler is also scientifically active and lectures at the University of Basel. He also was a visiting professor at Duke University (USA). Please do not hesitate to contact him if you wish a professional consultation!