Bicompartmental Breast Lipostructuring

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1 DOI /s ORIGINAL ARTICLE Bicompartmental Breast Lipostructuring M. L. Zocchi Æ F. Zuliani Ó Springer Science+Business Media, LLC 2007 Abstract 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 M. L. Zocchi (&) F. Zuliani C. S. M. Institute for Aesthetic Plastic Surgery, 4, via Guarini, Torino 10, Italy michelezocchi@michelezocchi.com (bicompartmental grafting). Any intraparenchymal placement is carefully avoided. Since 1998, 168 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

2 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. Keywords Adult stem cells Alloplastic materials Autologous adipose tissue Breast augmentation Breast lipostructuring Fat transfer Table 1 Limits and complications of intraparenchymal en bloc fat grafts (old technique) Strong inflammatory reaction Steatonecrosis Infections Liponecrotic pseudocyst Intraparenchymal microcalcifications Unpredictable results due to the almost complete reabsorption of the transplanted fat Autologous adipose tissue has been used to correct soft tissue defects for more than a century. Its soft and natural texture, the absence of a line, and its versatility have always made adipose tissue the ideal physiologic filling material. The first surgeons using adipose tissue as a filling material were Neuber [8], whose used it in 1893 to correct facial defects, and Czerny [3], who used it in 1895 to treat the sequelae of mastectomy. Since then, free grafts of adipose tissue also have been used extensively in several other fields of surgery including thoracic surgery (for filling tubercular cavities), general surgery (to stop bleeding after liver and kidney surgery), neurosurgery (for cranial defects to obviate cerebral adherence), and orthopedic surgery (to close bone defects). In the 1950s, Peer [9] was the first plastic surgeon to conduct extensive studies on the long-term survival of autologous fatty tissue grafts. He reported that these grafts lost more than 50% of their weight and volume after 1 year, and showed that most reabsorption occurred in the larger fatty tissue particles and during the first 3 months after the reimplantation. In the 1960s, interest in autologous adipose tissue grafting almost disappeared due to the ever-increasing use of dermal adipose grafts, which proved to be more reliable and long lasting. Furthermore, new artificial materials for soft tissue augmentation (paraffin, fluid silicone, methacrylate, and others) became very popular despite the high rate of complications. Until the 1980s, fat transplantation had been performed only as a soft tissue graft harvested en bloc with open surgery, thus resulting in evident and ugly scars at both the donor and receiving sites. Only in the mid-1980s did the diffusion of syringe liposuction [4,5,12], which standardized and popularized methods for harvesting fat in a simple and safe manner, arouse renewed interest in free fat transplantation. This has stimulated, since then, constant evolution and technical improvement. In 1986, Illouz [6] and Fournier [4,5] were the first to define lipofilling as microlipoextraction and reinjection for facial rejuvenation. Deeply involved in this field of investigation, Zocchi [14-17] in 1989 described a method for producing autologous collagen from fat manipulation for face sculpting and rejuvenation. Then in France, Fournier [4], extending his great experience and knowledge Fig. 1 Instruments: (a) Complete set with syringe, syringe holders, cannulas, and containers. (b) Special cannulas 2 mm in diameter, specially coated. (c) Vibrating table used for stratification of harvested material

3 Fig. 2 Functional anatomy of the breast. Fat constitutes more than half of the weight of most breasts, even small ones [7] Fig. 3 External skin expansion with BRAVA Ò.(a) The silicone-sealed cups are positioned over the breast. (b) The miniaturized pump is connected. (c) The containing bra supports the cups and pump Fig. 4 Donor-site selection with respect to the methameric theory, which postulates that fat reimplanted on the same side (left on left/right on right) from which it was harvested has a greater chance of survival

4 Fig. 5 Surgical planning. (a) Preoperative drawing delimitating the reimplantation sites on both the retroglandular and superficial planes. (b) Hypertrophy of the upper poles. (c) Postimplantation touch-up. (d) Severe hypotrophy. (e) Asymmetry Fig. 6 Fat harvesting

5 Fig. 7 Fat preparation. (a) Gentle washing with saline solution. (b) Stratification by vibration. (c) Stratification by decantation. (d) Conservation in cold saline of fat transfer to the face and other body areas, described a personal technique of en bloc intraparenchymal fat grafting into the breast. From January 1991 to December 1993, we used the Fournier technique for 41 patients, then discontinued its use because we were disappointed with the very high rate of complications (Table 1), and above all, with the lack of predictability and durability due to the almost complete ultimate reabsorption of the grafted fat. Our experience with this old technique reflected the controversial judgment of the international scientific community on it. Moreover, the literature review also indicated that all the complications observed were strictly related to technical errors during the harvesting and preparation of the fat, and most of all, to the technique and the anatomic site of reimplantation [13]. Furthermore, the well-known controversy over silicone gel-filled breast implants (resulting in law-enforced suspension of their clinical use for primary cosmetic augmentation mammoplasty in the early 1990s, first in the United States and then in many other countries), the nonacceptance of having artificial alloplastic materials in the body, and the residual scars still raise major concerns with some patients. The result is a specific contraindication for traditional augmentation mammoplasty. Considering the aforementioned problems and seeking to find safe and reliable alternatives to implants, we developed a new technique of fat transplantation for breast augmentation called bicompartmental breast lipostructuring [20,21]. This name takes its origin from the fact Fig. 8 Breast setup. (a) Antiseptic packing. (b) Nipple shield

6 Fig. 9 Fat transplantation. Fat tissue is inserted in two planes: retroglandular (a,b) and superficial (c,d) that fat tissue is rigorously reimplanted in two specific anatomic areas of the breast only. Materials and Methods Clinical Outcome From 1998 to 2007, 181 women with a mean age of 33 years were treated with the aforementioned technique. All the patients underwent major or mild body contouring at the same time, and 60% were treated for augmentation and volume asymmetry. Of the latter patients, 12% had a combined reductive mastoplasty for the contralateral breast using the ultrasound technique. Symmetric volume augmentation of both breasts was performed for 36% of patients, whereas 11% underwent correction of sequelae originating from previous breast surgery as well as augmentation (6%), reduction (2%), or mastopexy (3%). Instruments A specially designed Teflon-coated cannula 2 mm in diameter with a single lateral hole and connected to a disposable 60-ml syringe with a tapered tip is used to harvest the adipose tissue. A steel stopper device helps to maintain the vacuum in the syringe during the aspiration phase. Two specially designed cannulas (Fig. 1a and b) with the same features as the cannula used for harvesting are used to perform reimplantation of the fat: a straight flexible 27-cm-long cannula for the deeper retroglandular plane and a stiffer 25-cm-long curved one for reinjection of the fat in the subcutaneous plane and for redefining both the breast crease and the inframammary fold. Fat is not centrifugated, so no centrifuge is necessary. A vibrating table (Fig. 1c) and specially designed syringe holders are used to speed up the cleaning phase and the stratification process. The fat ready to be reimplanted is then preserved in metal cylindrical containers filled with cold saline. Technique We devised a new surgical technique that incorporates the most important recent contributions in functional anatomy of the breast [7] (Fig. 2) and fat transfer [1,2,14 17]. We aimed to find logical solutions to all the shortcomings observed in the earlier version of breast grafting and to obtain more predictable and stable results. The new technique involves eight technical steps:

7 Fig. 10 Manual reshaping. Fat tissue is carefully molded and reshaped to obtain a smooth and regular surface 1. External breast skin expansion (using BRAVA, BRAVA, LLC, Miami, FL) 2. Surgical planning (breast and donor areas) 3. Body contouring setup 4. Fat harvesting 5. Fat preparation 6. Breast setup 7. Fat transplantation 8. Manual reshaping.

8 Table 2 Rating of the aesthetic results Results Patients (n) Evaluation (%) Surgeon (n) Insufficient Fair Good Excellent Evaluation (%) Table 3 Complications of bicompartmental lipostructuring N % Edema Bruising Dysesthesia Liponecrosis Microcyst Microcalcifications External Breast Skin Expansion The patient is asked to wear a special breast expansion device (BRAVA) 30 days before surgery for 12 h a day. This device, invented and distributed worldwide by the American plastic surgeon Roger Khouri, stimulates vasculogenesis and lymphatic activity, opening the spaces to create the ideal situation for fat reimplantation. Unfortunately, this step requires high patient compliance and cooperation. Because of the discomfort in wearing the device, it is not always accepted. Whenever patients have cooperative in wearing BRAVA, the reimplantation phase has been facilitated and the rate of fat survival definitively higher (Fig. 3). Surgical Planning In the bicompartmental breast lipostructuring procedure, careful and precise planning of both donor (body) and receiving (breast) areas must be performed. Table 4 Radiologic follow-up evaluation Sonography, preoperative, 6 months, 1 year Mammography preoperative, 1 year (Fig. 11) Magnetic resonance imaging (MRI) on demand (Fig. 11) Donor site (body) The donor sites selected the most often are the trochanteric and gluteal regions, with respect, if possible, to the homolateral receiving hemisoma (right to right/left to left). This marking, done with the patient in the standing position, must be adapted to the different clinical situations (Fig. 4). Fig. 11 Mammography. (a) Before bicompartmental breast lipostructuring. (b) Enlarged volume of the adipose prefascial plane (radiotrasparency) after 1 year. (c) Magnetic resonance imaging (MRI) showing enlarged breast with normal healthy fat before surgery and (d) 1 year after surgery (R. Khouri)

9 Fig. 12 (a c) Preoperative views of a 30-year-old woman with a severe breast hypotrophy. (d f) Postoperative views 2 years after a bicompartmental breast lipostructuring procedure that reimplanted 290 ml of adipose tissue in each breast Receiving site (breast) The most empty areas of the superior quadrants and any volume asymmetry or discrepancy in height and position of the submammary fold are carefully marked preoperatively on the breast while the patient is in the standing position (Fig. 5). Body-Contouring Setup The bicompartmental technique often is used as a complement to extensive circumferential body-contouring surgery (ultrasonic lipoplasty). The patient is first disinfected in the standing position with a nonalcoholic solution to reduce the chance that the preoperative marking will be wiped off. General anesthesia then is induced on a surgical sterile bed. After the patient has been turned in the prone position onto another adjacent sterile bed, the areas to be treated are infiltrated with room-temperature saline using 2 mg of adrenaline per liter, usually starting from the left side of the body. Fat Harvesting Fat is harvested in a rigorous closed system using disposable tapered-tip 60-ml syringes and a 2-mm single-hole Teflon-coated special cannula (Fig. 6). The fat tissue usually is harvested only in the posterior areas of the body, with care to avoid, whenever possible, the inner face of the thighs and the abdominal area. During the harvesting phase, the surgeon must constantly remember to avoid creating asymmetries or irregularities at the donor sites. The relevant quantity of fat necessary for a bilateral breast lipostructuring is based on extensive knowledge concerning the principles of traditional body contouring and a respect for all its technical steps (planning, infiltration, deep plane, superficial plane). Fat Preparation After the harvesting phase, the fat tissue is prepared with minimal manipulation. A gentle washing with saline solution in the same syringe used for harvesting is done to remove all undesirable components (blood, saline, oil) (Fig. 7a). During the preparation phase, the syringes full of harvested fat tissue are maintained in an upside-down position with specially designed syringe holders. Then the syringes are placed for 30 s on a sterile vibrating device to speed up the stratification process, leading to separation of the harvested material into two main layers: fat tissue and fluid (Fig. 7b and c). Centrifugation is not necessary and not recommended in this procedure. Handling such a large quantity of fat for reimplantation (up to 2,000 ml) would dramatically increase the duration of this step. Furthermore, the centrifugation phase of 5 min at 3,000 rpm, as described by Coleman [1 3], has been demonstrated to increase the apoptotic death rate for adult mature adipocites. [10,14 17]. After preparation, the harvested adipose tissue is preserved in the same syringes used for harvesting plunged in cold saline (Fig. 7d). Breast Setup Once the harvesting and the body-contouring phases are completed in the posterior areas, the patient is turned over

10 Fig. 13 (a c) Preoperative views of a 23-year-old woman with moderate upper pole breast hypotrophy. (d f) Postoperative views 1 year after a bicompartmental breast lipostructuring procedure that reimplanted 310 ml of adipose tissue in each breast on the surgical table and placed in the supine position for completion of the anterior body contouring and for the breast lipostructuring. During all this time and until the moment of reimplantation at the very end of the surgery, an iodine solution (Betadine) packing is applied to the breast area. The nipples are protected by adhesive nipple shields to avoid any contamination of the grafted area by accidental spreading of glandular secretions, often at the origin of inflammatory and infectious reactions (Fig. 8). Fat Transplantation Fat is reimplanted through a small incision made with a no. 11 blade in the medial portion of the inframammary fold. Two specially designed self-lubricated 2-mm cannulas are used for this step: a straight flexible 27-cm-long cannula for the deeper retroglandular plane and a stiffer 25-cm-long curved one for reinjection of the fat in the subcutaneous plane and for redefining the breast crease and the inframammary fold. The fat transplantation technique is performed only into the retroglandular/prefascial plane and into the superficial subcutaneous tissue of the upper pole of the breast (bicompartmental grafting) in hundreds of retrograde paths, with care to avoid any intraparenchymal placement. After insertion, the cannula should stay parallel to the chest-wall and then proceed upward through the retroglandular space, always in touch with the pectoralis aponeurosis until it reaches the superior preoperative marks (Fig. 9a), As its tip goes beyond the gland, keeping on the same level in this area, it actually ends up being in the subcutaneous plane. The first fat-filled syringe is connected (Fig. 9b). The assistant s hand should be used as a barrier to prevent any accidental spreading of fat in undesired areas.

11 Fig. 14 (a c) Preoperative views of a 44-year-old woman with moderate upper pole breast hypotrophy. (d f) Postoperative views 1 year after a bicompartmental breast lipostructuring procedure that reimplanted 300 ml of adipose tissue in each breast After completion of fat insertion behind the gland, the adipose tissue is injected along the inframammary crease and the breast medial border. At this time, a curved cannula should be used to allow grafting along the rounded outline. The curved cannula is kept in a strictly subcutaneous plane and must be rotated by 90. At the end, its tip will be oriented upward, with its hole facing the dermis, to prevent fat from being injected too deeply. The adipose tissue is injected as the cannula is withdrawn. The amounts should be limited to the bare minimum needed to fill up the tunnels left by the cannula (i.e., 2 3 ml of fat for each tunnel). Any excess could determine surface irregularities. At the end of the procedure, the incision must be meticulously and tightly sutured with a reabsorbable thread (Fig. 9a d). Manual Reshaping Next, implanted fat tissue is carefully distributed to obtain a very regular and smooth surface. The aim of this important and delicate phase is to reproduce the shape of an anatomic implant, especially in the upper pole, where it is important to create a natural and physiologic fullness, avoiding excessive roundness or unaesthetic stepping. Once fat grafting has been completed, the adipose tissue is redistributed and molded so as to flatten out any irregularity along the borders. About 10 ml of Vaseline oil are used as a lubricant. This maneuver, performed using both fingertips and the radial edge of the hand, requires much pressure, but does not damage the adipocytes because compression is exerted on the tough bony surface rather than on the grafted fat itself.

12 Fig. 15 (a c) Preoperative views of a 42-year-old woman who underwent surgery 2 years previously for a round-block mastopexis presenting with a moderate loss of volume in the upper poles of the breast, insufficient projection of nippleareolar complex, and diffused skin irregularities. (d h) Postoperative views 6 months after a bicompartmental breast lipostructuring procedure that reimplanted 350 ml of adipose tissue in each breast Peripheral squeezing maneuvers are performed along the marked curved mammary outline while the whole breast surface is carefully checked for detection of any superficial unevenness. It should be noted that all this will not displace the fat in undesired areas because the latter has been inserted following crisscross vectors. Consequently, septa of connective tissue act as a barrier, preventing any adipose tissue from sliding beyond the traced breast border. This desirable fence effect will last during the whole healing process. At the end of the treatment, an elastic roll is fixed to maintain the space between the breasts, and a sports bra with shaped cups and no wire is used to support the breast for 4 weeks (Fig. 10a g).

13 Fig. 16 (a d) Preoperative views of a 54-year-old woman showing a severe loss of volume in the upper poles of the breasts, poor definition of the mammary crease, and asymmetries 6 years after reductive mastoplasty. (e h) Postoperative views 6 months after a bicompartmental breast lipostructuring procedure that implanted 500 ml of adipose tissue in the left side and 400 ml in the right side Results Since 1998, a total of 181 patients have undergone the aforementioned procedure (145 bilateral and 36 monolateral), for a total of 326 breasts. Grafted fat volume has ranged from 160 to 745 ml (average, 375 ml) per breast. Volume persistence at 1 year was up to 70% (average, 55%). It is noteworthy that transplanted fat reabsorption was significantly reduced, thanks to the improved harvesting and grafting technique and, above all, to the choice of reimplantation site. A few patients who had undergone simultaneous extensive body contouring (ultrasonic megalipoplasty) and had lost significant weight after the surgery sometimes

14 Fig. 17 (a c) Preoperative views of a 56-year-old woman with too visible breast implants, insufficient soft tissue coverage, and poor crease definition. (d f) Postoperative views 2 years after a bicompartmental breast lipostructuring procedure that reimplanted 300 ml of adipose tissue in each breast complained about an insufficient volume increase. More often, patient satisfaction was higher than surgeon satisfaction (Table 2). The most common side effects during the first 2 weeks after surgery were localized edema and slight bruising. Overall, complications (Table 3) were minimal and temporary. Three cases of pseudocysts resolved spontaneously over a period of 6 months. In a series of 171 patients treated with the described procedure during an 8-year period, to date, only 6 cases of microcalcifications have been monitored (rate of 3.9%): one bilateral in the upper pole and the others unilateral in the prefascial retroglandular plane. All the patients were carefully monitored with preoperative and serial postoperative mammograms and ultrasonograms (Fig. 11). This close follow-up evaluation allowed us to clarify the most controversial aspect of microcalcifications, which has been the main point of criticism for this procedure over the years. Microcalcifications cannot be completely prevented, and they can occur in response to any trauma or surgery to the breast. However, they are very different in appearance and location and generally can be distinguished easily from those appearing in the context of a neoplastic focus. For instance, it also is very important to clarify that all the other breast surgeries lead to the formation of microcalcifications, with the highest rate (\15%, Sadove [11]) related to reduction mammoplasty. A correct radiologic follow-up assessment (Table 4) and a meticulous record of the surgical procedure usually have been sufficient to clear any diagnostic concern. Good communication with the radiologists is mandatory. In those rare instances of persistent doubt, we could be confronted by a false-positive, and although this generates distress in

15 Fig. 18 A very interesting case of a 20-year-old woman. At the age of 15 years, she underwent an augmentation mammoplasty of the left breast only to correct a severe hypoplastic left breast and the related asymmetry. At first observation, the patient showed a severe asymmetry with excessive volume of the left breast. The patient also complained of stiffness, irregularities of profile, and contraction of the left breast (a). The implant was removed (b d), and after 6 months, extensive lipoplasty of the body and bi-compartmental breast lipostructuring was performed to reimplant 435 ml of adipose tissue in the left breast only. View 1 year after surgery (e,f) the patient, it can be easily clarified with a simple tridimensional (stereo-tassic) biopsy. Clinical Experience Figures 12, 13, 14, 15, 16, 17, 18 Conclusions Current techniques for augmentation mammoplasty involve the use of alloplastic materials and an open approach. The former may not be well tolerated and often can be the origin of undesirable effects such as capsule contracture. The latter implies residual scars, which can sometimes be less than satisfactory from an aesthetic point of view. Constant research in this field, progressive improvement in design and biocompatibility of breast implants, and the evolution of surgical techniques have led to shorter and better-hidden scars, reducing, however, only partially all the aforementioned shortcomings and problems. Furthermore, the well-known controversy over silicone gel-filled breast implants, which in the early 1990s resulted in a suspension of primary cosmetic augmentation mammoplasty from clinical use in the United States, has not been completely overcome, and still raises concerns with some patients. A thorough review of the literature suggests that all the common complications observed in the past can be attributed to methodologic errors, mainly related to the technique for harvesting and to the anatomic site of reimplantation. There is no evidence or proof of specific problems related to the intrinsic features of the fat tissue itself as augmentation material. In fact, the use of fat for correction of volumetric soft tissue defects is almost 100 years old, first accomplished with an open surgical approach and then with less invasive techniques. Its softness, good tolerance by the body, and versatility in many clinical situations make fat the most desirable autologous filler material. Therefore, we wish to call the attention of the international scientific community to a controversial and, in the past, abandoned procedure. All recent technical and clinical advances have minimized complications and dramatically increased transferred fat survival and volume persistence. If well done, bicompartmental breast lipostructuring can be the most viable and safe alternative to the use of prosthetic material for breast augmentation in selected cases (Table 5). It offers to both patients and surgeon many benefits and advantages (Table 6). A very common observation is the fact that the majority of the patients treated with bicompartmental breast

16 Table 5 Indications for bicompartmental breast lipostructuring Contraindications or refusal of implants Moderate volume expectation Moderate mammary ptosis Volume loss in mammary upper pole Asymmetries Implant irregularities (wrinkles, steps, rippling) As a complement of a body contouring Table 6 Benefits of bicompartmental breast lipostructuring Minimally invasive procedure Unnoticeable scar Realizable in local anesthesia Short recovery Ideal complement to a body contouring procedure Push-up effect Natural look Natural touch Improved quality of skin texture lipostructuring present with consistently improved skin quality in terms of both elasticity and texture. Skin stretch marks, especially in the lateral area and around the nippleareola complex, very often are less evident. This evidence confirms that the transfer of fat tissue acts not only as a volume replacement, but also as a tissue regenerator. This observation is supported by the most recent studies on adult stem cells contained in adipose tissue, conducted by us and others groups worldwide [2,18,19]. The most advanced research has been able to demonstrate that adipose tissue presents the same high potential of growth as mesenchymal totipotential bone marrow stem cells. However, the harvesting of bone marrow is definitely more traumatic and limitative. In contrast, adipose tissue can represent an inexhaustible source of easy and immediately available mesenchymal cells for clinical application in all areas of medicine that care for the regeneration of autologous tissue. In fact with a modest quantity of adipose tissue, we have demonstrated that it is possible to obtain, through rigorous isolation and culture techniques, a large quantity of totipotential stem cells that can eventually be differentiated easily according to various needs (adipose, cartilaginous, bone, endothelial, muscular, hepatic tissues and pancreatic cells). For all the aforementioned benefits, if well performed following all the technical steps, bicompartmental breast lipostructuring should be considered a safe and viable alternative to traditional augmentation mammoplasty for all cases in which additive mastoplasty with implants is either unsuitable for the patient or unacceptable to her. However, it is not our intention to propose this method as a complete substitute for breast augmentation with alloplastic implants. The achievable volume and projection of the mammary cone still are limited, even if augmentation is mainly localized at the upper pole, the most critical area of early aging and volume loss. References 1. Coleman SR (1997) Facial recontouring with lipostructure. Clin Plast Surg 24: Coleman SR (2006) Structural fat grafting: More than a permanent filler. Plast Reconstr Surg 118(3 Suppl):108S 120S 3. Czerny V (1895) Plastischer Ersatz der Brustdruse durch ein Liporna. Chir Kongr Verhandl 2: Fournier P (1986) La liposculture. Arnette, Paris 5. Fournier P (1985) Microlipoextraction et microlipoinjection. Rev Chir Esthet Fr X: Illouz YG (1986) The fat cell graft: A new technique to fill depressions. Plast Reconstr Surg 78: Lejour M (1997) Evaluation of fat in breast tissue removed by vertical mammaplasty. Plast Reconstr Surg 99: Neuber F (1893) Fettransplantation. Chir Kongr Verhandl Dsch Geselsch Chir 22:66 9. Peer LA (1950) Loss of weight and volume in human fat grafts with postulation of cell survival theory. Plast Reconstr Surg 5: Rigotti G, Marchi A, Galiè M et al (2007) Clinical treatment of radiotherapy tissue damage by lipoaspirate transplant: A healing processpediated by adipose-derived adult stem cells. Plast Reconstr Surg 119: Sadove R (2004) Reduction of the breast with liposuction only. First European symposium. Aesthetic surgery of the breast, Milan 9-11 December Toledo LS, Mauad R (2006) Fat injection: A 20-year revision. Clin Plast Surg 33: Valdatta L, Thione A, Buoro M, Tuinder S (2001) A case of lifethreatening sepsis after breast augmentation by fat injection. Aesth Plast Surg 25: Zocchi ML (1988) Production de collagène autologue par traitement du tissu adipeux avec ultrasons. Congrès de la Société Française de Chirurgie Esthétique, Paris, May 15. Zocchi ML (1989) Les implant mixte de collagène autologue dans le remodelage facial. Rev Chir Esthét Fr 14: Zocchi ML (1989) Remodelage facial complet par implants de collagène autologue. Revue Française de Chirurgie Esthétique 14: Zocchi ML (1990) Methode de production de collagène autologue par traitement du tissue graisseux. J Med Esthét Chir Dermatol 17: Zocchi ML (2006) Stem cells from fat. Abstract book of 10th Annual Meeting of the Turkish Society of Aesthetic Plastic Surgery, June 19. Zocchi ML (2006) New perspectives in plastic surgery: Adiposederived stem cells (ADSC.).Abstract Book of the I.S.A.P.S. World Congress of Rio de Janeiro, August 20. Zocchi ML (2007) Bicompartmental breast lipostructuring. E- Poster IPRAS World Congress, Berlin, July 21. Zocchi ML (2007) Bicompartmental breast lipostructuring. In: Botti G (ed) Aesthetic mammoplasties. SEE, Florence, October