Autologous fat injection into the pectoralis major as an adjunct to surgical correction of gynecomastia

The Optimal Layer for Breast Augmentation in an Autologous Fat Grafting Murine Model

BACKGROUND

Fat grafting is an effective procedure for breast augmentation, but the variations in this technique result in unpredictable fat retention. Therefore, animal models are needed to simulate the operation and the optimal layer for fat retention.

OBJECTIVES

An autologous fat grafting murine model for breast augmentation was built to detect a new layer for fat grafting in the chest.

METHODS

The left side of the female rat inguinal fat flap was harvested, dissected into small pieces, and autotransplanted into 3 different layers of the breast. Retention rate and hematoxylin and eosin (H&E) staining were measured at 1, 4, 8 12, and 16 weeks. Immunofluorescence staining was utilized to detect adipocytes and endothelial cells, and immunohistochemistry was conducted to evaluate the expression of integrins β1 and α6.

RESULTS

The volume of fat grafts slightly grew in the intramuscular and submuscular layers at Week 4. Retention rates in the subcutaneous layer and submuscular layer were significantly higher than the intramuscular layer at Week 16. H&E staining showed that oil cysts existed in the subcutaneous layer throughout the 16 weeks. At the terminal time point, well-vascularized mature adipose structures were observed in intramuscular and submuscular layers, with smaller adipocytes in intramuscular layers. Immunohistochemistry analysis showed that integrin β1 was identically expressed in every adipocyte in all the layers, whereas integrin α6 selectively expressed in bigger adipocytes in the intramuscular layer. The expression intensities of integrin β1 and α6 were significantly higher in the intramuscular layer than in the subcutaneous and submuscular layers.

CONCLUSIONS

The angiogenic and moderate mechanical environment makes the submuscular layer the optimal layer for fat retention.

Anthropometric Measurements and Analysis for Objective Assessment of Gynecomastia Surgery Results

Background

Gynecomastia surgery is one of the most common aesthetic procedures in males. There is a lack of objective analytical parameters to judge outcomes. In this study, the authors aim to introduce novel anthropometric measurements and analysis techniques for the objective assessment of surgical outcomes based on specific aesthetic targets.

Objectives

To introduce quantification of gynecomastia surgery outcomes and compare the results among the different grades of gynecomastia.

Methods

A total of 192 patients with gynecomastia were included. The patient cases were grouped according to grades and a set of anthropometric measurements were taken both before the operation and 6 months postoperatively. Liposuction and glandular excision were done through minimal incisions in all grades of gynecomastia, with the addition of ultrasound and nipple areola complex (NAC) lifting plaster in selected Grade 3 and all Grade 4 cases.

Results

A statistically significant improvement in the perimeter of the triangular relationship of sternal notch and nipples, the elevation of the NAC, the reduction of the area of the NAC, and the correction of asymmetry of the chest were seen in all grades of gynecomastia, with increased differences in higher grades.

Conclusions

A systematic objective analysis of the specific aesthetic targets helps to reliably compare results in a standard way and for carrying out improvisation of surgeons' techniques. Meanwhile, this approach helps identifying the need for customization, eventually providing symmetric and aesthetically pleasing surgical results.

Level of Evidence 3

Male Pectoralis Major Muscle Augmentation with Autologous Fat Transplantation Using VASER Lipoaspirate: Evaluation with MRI

The popularity of autologous fat grafts has increased for the reshaping, contouring, and augmentation of the male breast tissue. However, long-term maintenance of tissue viability and the ways for assessment serve as hot-spot topics in the field. This study was designed to evaluate the viability of fat grafts obtained by a vibration amplification of sound energy at resonance (VASER)-assisted lipoaspiration procedure using a magnetic resonance imaging-based approach.

Methods

This is a prospective examination of 20 male patients (40 breasts) who underwent VASER-assisted liposuction and fat grafting surgery, and long-term fat graft viability was evaluated by magnetic resonance imaging scans.

Results

Participants had an average age of 34.85 ± 7.37 years with a mean BMI of 26.73 ± 2.63 kg/m². The mean fat graft volume injected was 542.63 ± 144.78 mL on the right, and 548.95 ± 140.36 mL on the left side. On the magnetic resonance imaging follow-up, the mean intrapectoral adipose tissue thickness was 20.34 ± 6.31 mm on the right, and 18.94 ± 8.27 mm on the left sides and tissue viability was preserved in all cases. The mean follow-up duration was 22 ± 9.8 (range 14-44) months.

Conclusion

VASER-assisted lipoaspiration and autologous fat grafting of the major pectoralis muscle provide a satisfactory outcome and long-term maintenance of the grafted adipose tissue.

Adipose Tissue Transfer in Dynamic Definition Liposculpture-PART I. Back: Latissimus Dorsi and Trapezius Muscles

The aesthetics for the male posterior torso remain a topic not fully studied in body contouring surgery, neither the lipoinjection of its muscles have been considered before. As a result, we carried out a retrospective cohort study including patients who underwent fat grafting of either the trapezius or the latissimus dorsi muscles as part of dynamic definition liposculpture (HD2).

Methods

We performed cadaveric dissections to support the fat grafting technique for both the trapezius and the latissimus dorsi muscles. We also searched our records for patients who underwent fat grafting of these muscles in addition to HD2 from January 2016 to November 2021 at a single center in Bogotá, Colombia.

Results

Thirty-five consecutive patients met the inclusion criteria. In total, 22 (63%) and 7 (20%) of 35 underwent fat grafting at the trapezius and the latissimus dorsi muscles alone, respectively, and 6 out of 35 (17%) of both. Mean age is 39 years (range = 22-63). All patients were men. No complications were recorded related to fat grafting. Almost all patients were satisfied with the procedure (97%). Follow-up period ranged from 2 to 48 months.

Conclusions

Liposuction might not be enough to achieve the ideal V-shape of the men's back in some cases; hence, fat grafting of the power muscles becomes the best option. Recognition of the main neurovascular pedicle, proper preoperative markings, and a correct surgical technique ensure both the safety and the reproducibility of the technique.

Surgical Decision Making in Autologous Fat Grafting: An Evidence-Based Review of Techniques to Maximize Fat Survival

Autologous fat grafting is an important tool in plastic surgery and is widely used for a variety of applications, both aesthetic and reconstructive. Despite an ever-increasing list of indications and extensive research over many years into improving outcomes, fat grafting remains plagued by incomplete and often unpredictable graft survival. Decisions made at each stage of surgery can potentially contribute to ultimate success, including donor site selection and preparation, fat harvest, processing, and purification of lipoaspirate, recipient site preparation, and delivery of harvested fat to the recipient site. In this review, we examine the evidence for and against proposed techniques at each stage of fat grafting. Areas of consensus identified include use of larger harvesting and grafting cannulas and slow injection speeds to limit cell damage due to shearing forces, grafting techniques emphasizing dispersion of fat throughout the tissue with avoidance of graft pooling, and minimizing exposure of the lipoaspirate to the environment during processing. Safety considerations include use of blunt-tipped needles or cannulas to avoid inadvertent intravascular injection as well as awareness of cannula position and avoidance of danger zones such as the subgluteal venous plexus. We believe that using the evidence to guide surgical decision-making is the key to maximizing fat grafting success. Level of Evidence: 4.

Gynecomastia Treatment through Open Resection and Pectoral High-Definition Liposculpture

BACKGROUND

Male chest definition surgery and patients complaining of breast tissue overgrowth have been increasing in recent decades. After the authors' first report of pectoral etching in 2012, patients and surgeons became more aware about gynecomastia resection when performing pectoral enhancement. The authors present their experience with pectoral high-definition liposculpture in addition to inverted-omega incision resection for gynecomastia.

METHODS

The authors reviewed their records on pectoral high-definition lipo sculpture between January of 2005 and October of 2019 in four surgical centers in Colombia. Inclusion criteria were as follows: men diagnosed with gynecomastia and body mass index less than or equal to 32 kg/m2, adequate skin elasticity, and general good health. Photographs were taken preoperatively and 1, 3, 6, and 12 months postoperatively. Follow-up ranged from 2 months to 3 years.

RESULTS

Gynecomastia resection plus high-definition liposculpture was successfully performed in 436 consecutive men (open inverted-omega incision resection, n = 132; liposuction, n = 304). Ages ranged from 18 to 66 years. Fat grafting volume ranged from 50 to 300 cc in each pectoral muscle. Minor complications (3.2 percent) included prolonged swelling, bruising, asymmetries, and residual gynecomastia. Major complications (1.6 percent) included unilateral hematoma and localized infection. No necrosis, systemic infection, or muscle paralysis was reported. A nonstandardized survey showed a very high satisfaction index.

CONCLUSION

Gynecomastia treatment combining high-definition liposculpture to male breast tissue resection through a new, almost invisible incision allowed us to achieve an athletic and natural appearance of the male pectoral area with a very low rate of complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Masculinized Male Chest Contouring: Creating the Armor Plate

Male patients are routinely consulted regarding dislike of their chest appearance. To date, majority of patients have desired elimination of their feminine-appearing breast, termed gynecomastia. These patients have associated their overweight body image, with the femininity of their breasts as presented by fullness and roundedness of their breasts and subsequently have desired maximal flattening of their breast. We present a new set of patients who desire a more muscular-appearing chest than a gynecomastia repair that is interposed on a chiseled abdominal contour. In contrast to the former set of patients, these patients desire bulking of their breasts with a bolder-appearing armor plate look. We present an alternative to traditional gynecomastia repair which involves a novel approach to chest contouring creating a flat, yet bold, pentagonal-shaped breast with linear borders utilizing both fat and gland removal as well as strategic fat grafting back into the chest. We present a novel protocol to create an armor plate male chest appearance as an alternative to traditional gynecomastia contouring. All patients treated to date demonstrate a muscular-appearing chest that is harmonious on an interposed masculine-appearing abdomen.

From Bedside to Bench: The Effect of Muscular Denervation on Fat Grafting to the Breast by Comparing Take Rate, Quality, and Longevity

BACKGROUND

Autologous fat grafting (AFG) to the breast is a frequent procedure in aesthetic and reconstructive surgery. Despite pure volume gain, questions remain regarding the engraftment rate, quality, and longevity. Little is known about the role of recipient tissue or innervation of the grafted area.

OBJECTIVES

The goal of this study was to determine the optimal recipient layer and muscular pretreatment of AFG.

METHODS

Fat was grafted to the breast, pectoralis muscle, or adjacent subcutaneous tissue of 42 rats. Nerve treatment included excision of a nerve segment, botulinum toxin (BTX) injection, or no treatment. Magnetic resonance imaging (MRI) and histological workup were carried out after 2 and 6 weeks.

RESULTS

Six weeks after AFG, the proportion of viable fat cells within the grafted fat stayed high (median, [IQR]: 81% [72% to 85%]). The signs of inflammation decreased over time. Intramuscular grafting with intact nerves had a decreasing effect on the viability of the grafted cells compared with subcutaneous treatment (-10.21%; 95% confidence interval [-21.1 to 0.68]).

CONCLUSIONS

If utilized on an intact nerve, intramuscular injection may lead to inferior results. If the nerve was cut or treated with BTX; however, intramuscular injection tends to be superior. These findings may prove interesting for future studies and eventual clinical application.