Observation on the Clinical Effect of Breast Augmentation by Transplanting Concentrated Growth Factor and Autologous Fat

Ling-ling ZHAO,Qing-chun XI,Ming-song FANG,Xuan LI,Ling CAO,Pong-fei SANG,Chang LIU

Department of Burns and Plastic Surgery,The Second people’s Hospital of Hefei,Anhui Province,230000 ,China

ABSTRACT Objective To explore the effect of concentrated growth factor(CGF)combined with autologous fat transplantation in augmentation mammoplasty.Methods Clinical data of 28 female patients who underwent autologous fat by CGF mixed with purified fat between May 2015 and June 2018 were retrospectively analyzed.Clinical evaluation was performed to observe and measure the shape of the breast after breast augmentation,the increase in the value of the nipple plane measurement,and complications.Results All of 28 patients,after 12 months of follow-up,all patients no fat infection,hematoma,breast nodules and other complications.It showed that the contouring of breast were improved and more chubbiness than that before operation.The results were satisfied from patients.Conclusion Concentrated growth factor combined with autologous fat transplantation has a stable breast augmentation effect,beautiful breast shape,simple operation and small damage,which achieves breast rejuvenation

KEY WORDS Concentrated growth factor;Breast augmentation;Autologous fat transplantation;Breast rejuvenation

Congenital breast flattening and atrophy of breasts after lactation can lead to sensitivity and self-abasement for various of women.Problems like this are preferred to be solved through breast augmentation surgeries.At present,silicone prosthesis is the mainly used material in the clinical application of these surgeries.However,surgeries using silicone prosthesis have the disadvantages of hematomas,capsular contracture,prosthesis migration as well as shape stiffness[1,2],and thus being not preferred among the patients.Meanwhile,the breast augmentation by transplanting autologous fat becomes more and more popular.Such surgeries have the advantages of abundant sources and authentic shapes.Besides,these surgeries can also concurrently accomplish fat reduction of other body parts by filling the breast through the fat that originally from waist,belly,or thighs.Yet the application is also limited by the uncertainty of the survival rate of transplanted fat[3].Concentrated growth factor (CGF)is the blood extract contains multiple high-concentrated growth factors,which are made by continually centrifuging autologous peripheral blood through special dedicated devices.CGF can promote the repair and regeneration of tissues,which could bring about fine effects in facial filling.In this paper,the author conducted breast augmentation by filling both CGF and autologous fat,and the results were rather good.The report is as follows.

CLINICAL DATA

The data of 28 cases of female beauty seekers who were operated by the breast augmentation by filling both CGF and autologous fat granule in our hospital from May 2015 to June 2016 were retrieved.Their age varied from 22 to 45,and the average age is 30.02.3.Eighteen cases of them had the history of giving birth and breastfeeding,while the other ten cases had flat breasts without breastfeeding.These beauty seekers were all healthy and had plenty of fat in their waists,bellies,and thighs.

OPERATION METHOD

Preoperative Preparation

First of all,the preoperative routine examination including blood and urine routine,hepatic and renal function,blood glucose and lipids,blood coagulation,immunity,chest radiograph,electrocardiogram and etc.should be completed.Next,breast color Doppler ultrasound should be conducted to see if the patients were suffering from breast diseases.The doctors would then communicate with our patients to figure out the shaping areas and mark the liposuction range with a marking pen.Finally,the venous blood volume needed would be told to patients,and the operation consent will be signed.Rohrich et al.’s research[4]found that the survival rates from fat from waist,belly,and thighs had no significant difference,and thus they all can be used as the liposuction part.

Anesthesia Method

The patients were all under general anesthesia through endotracheal intubation.

Preparation of Transplanting Fat Granule

First,applying tumescent anesthesia in donor area.The anesthetic liquid was allocated by mixing 1000 ml of 0.9% sodium chloride solution,20 ml of 2% lidocaine solution,and 1 mg of epinephrine.Sodium bicarbonate wasnotincludedatthis pointinorder toreduce the damageandthe saponificationreaction offatcells[5].

Next,preparing for liposuction.The entry point for liposuction in the waist and belly was generally above the inner edge of the umbilicus and above the inner edge of anterior superior iliac spine on both sides.The entry point for liposuction in thighs could be at the inner groin or in the folds of hips.The sharp blade picks up a length of about 2 mm.A slit about 2 mm long was picked by using a sharp blade.

Then applying the liposuction.By using the water injection mode on the liposuction and following the principle of “spread to fan-shaped from deep to sallow”,the tumescent anesthetic liquid was injected until the skin was “orange-peel-like” and the entry point was“spring-like”.Slightly patting the swelling area till the epinephrine was working.Connecting the 2mm porous blunt liposuction needle to the 20 ml syringe.Using the left hand to grab or press the liposuction area in order to confirm the position of the liposuction needle and the thickness of the subcutaneous fat.Using the right hand to pump back the syringe in order to form vacuum negative pressure.The suction should be repeated from deep to shallow.It should be noted that repeated suction at one point and swallow suction at the beginning are both supposed to be avoided in case of leading to irreparable unevenness.The extracted fat was standing vertically,and its total volume was around 500 ml.

Finally,removing the tumescent liquid and washing the fat granule twice with normal saline.Draining the water content,picking up the fibrous connective tissue,and cutting up relatively large fat granule to obtain minced fat with lower water content.Eto et al.[6]has pointed out that fat cells with 0.2 mm radius or below were more likely to survive.Therefore,the injecting fat granule should be as small as possible.Around 400 ml of dry fat granule could be obtained after draining.

Preparation of CGF

The CGF can be prepared by centrifuging full blood through the special CGF program on the Medifuge Centrifuge (Silfradent,Italy).This centrifuge has the technique of continuous speed differential centrifugation.The autogenous venous blood of patients can be extracted by using the matched 9 ml Vacuette vacuum collection tube.The blood samples should be placed into Medifuge Centrifuge immediately and starting the program of CGF preparation.The centrifuging program is:accelerating for 30 s until the speed is 2700 r/min and rotating for 2 min;speeding down to 2400 r/min and rotating for 4 min;accelerating to 2700 r/min again and speeding for 4 min;then accelerating to 3300 r/min and rotating for 3 min;at last,easing the speed down for 36 s until the device is stopped[7].After 13 min of centrifugation,the blood in the test tube was divided into three layers.During the centrifugation of the blood,the erythrocyte submerged into the lowest layer due to its fastest sedimentation velocity;the sedimentation velocities of CGF,leukocyte,and the blood platelets were not significantly different and slower than that of erythrocyte,thus submerging in to the middle layer;and the uppermost layer was the light yellow platelet-poor plasma (PPP).After preparing 9 ml of full blood,4 ml of liquid CGF was obtained and mixed with the prepared fat granule in the proportion of 1:20.The beauty seekers could withstand 400 ml of fat injection and 50 ml of venous blood extraction at one time.Mixing up the liquid CGF and the fat granule and transferring the mixture into the 20 ml syringe.Then transferring to multiple of 1 ml syringes as standby.

Injection Filling of Breasts

Picking a 2 mm slit through a sharp blade at the plica under breasts.In necessity,auxiliary incision could be made on the mammary areola or the outer side of breasts.Forming some cavity tunnels by using the fine blunt water-injection needle to infiltrate normal saline under the skin,under the breasts,and under the pectoralis major.The special needle for fat filling is a single-hole blunt stainless-steel needle with a length of 20 cm and an outer diameter of 2.5 mm.Following the principle of “multipoint,multi-level,and multi-tunnel radial injection”,the fat was injected by pushing back and forth repeatedly from the back of pectoralis major,the back of the breasts,and under the dermis.The fat granule in the cavity tunnels were arranged in a bead-like manner.For the patients with sagging breasts,the top of the breasts and the areola and around were the focused filling area.The lower layer of the dermis should also an emphasis,which could bring about significantly improvement of the elastic texture of skin.The posterior space of the mammary gland is a natural cavity that is rich in vascular nerves.This is conducive to the survival and the proliferation of transplanted fat[8].Then adjusting the size based on the shape of the two breasts.The injection volume per side was about 200 ml.If the breast bottom was larger,then filling the layers at the ratio of 1.5:6:2.5.If the breast bottom was small,then filling the layers at the ratio of 2.5:5:2.5.Increasing the thickness of the anterior chest,and finally trimming the necrotic tissue of the skin edge on the liposuction incision.Reserving 6-0 beauty line at the incision of the lower plica for knotting,and the remaining injection incisions were directly seamed.

Precautions after Operation

The liposuction areas in waist,belly and thigh are supposed to be wrapped with cotton pads and elastic bandages.After two days,the exudation would be reduced and then the reserved line should be knotted.After taking out the stitches,the patients should wear corsets for three months.The breast incision should be processed with simple dressing.In principle,the breast only needed to be simply fixed by tapes.Seven days after operation,the patients should wear the sports underwear for three months and local violent strikes and kneading should be avoided.Antibiotics and hemostatic drugs were supposed to be routinely used for 4 days.

Second Operation

After half a year,the effect of operation would be stable.If there was no obvious contraindication,then the second operation should be conducted.The filling volume for per side was also about 200 ml.The injected fat on the second operation should be easier to survive because the breasts of patients were larger than the first operation and the number of cavity tunnels were also increased.

RESULTS

According to the one-year follow up of the patients,breasts were significantly enlarged in a total of 28 cases(see Table 1).The effect of the second operation was even more obvious than the first time.The breasts were naturally shaped and soft to touch.The sizes of their breasts were stable sizes,and the skin elasticity was improved.Therefore,the operation results were quite satisfactory (see Figures 1 and 2).No complications such as infection,hematoma,and breast induration occurred.Also,no loculated cystic effusions were found in the breast color Doppler ultrasound examination.

DISCUSSION

Breast is one of the secondary sexual characteristics of women.Some women always feel inferior and miserable because of congenital breast flattening or sagging breasts and skin shrinkage due to breastfeeding.The medical scientists have tried various methods to increase the size of breasts.Among these methods,the most representative ones are to fill breasts with the silicone prosthesis and the autologous fat granule granular.Prosthetic breast augmentation has immediate effect,but its defects,such as capsule contracture and deformity,prosthesis displacement,stiff shapes,hematoma after surgery,obvious scar of surgical incision,damages of breast and pectoralis major,nerve and vascular injury,are also obvious.Therefore,more and more beauty seekers tend to ask for autologous fat transplantation.

Compared with prosthetic breast augmentation,autologous fat transplantation has many advantages.However,its application is also limited due to the high absorption rate of transplanted fat,infection,callosity reaction,and necrosis[9].Therefore,how to improve the survival rate of transplanted fat and reduce its complications has become the focus of the research in this filed.In recent years,there have been many reports on how to improve the survival rate of transplanted fat.The commonly used methods include cell-assisted fat transplantation,hydrodynamic assisted liposuction,and external expansion techniques that assisting fat transplantation.Cell-assisted fat transplantation refers to add some cytokines containing autologous fat transplantation (CAL) rich in adipose-derived mesenchymal stem cells,platelet-rich plasma (PRP),andvascular endothelial growth factor (VEGF) during fat transplantation.The first two are the most commonly used cytokines.Although there are many successful cases of using CAL for breast shaping surgeries inside our country and abroad,some research based on basic experiments show that safety hazards still exist in the use of adiposederived mesenchymal stem cells (ADSCs) for breast shaping surgeries[10].Thus,the use of adipose-derived mesenchymal stem cells for assisted fat transplantation should be cautious,and more clinical trial evidence is needed to rule out the possibility of causing disease.Studies have reported that plasma concentrates rich in cell growth factors,such as platelet-rich plasma (PRP)[11]and platelet-rich fibrin (PRF)[12]can accelerate early revascularization and inhibit apoptotic necrosis of fat cells during fat transplantation and.Mixed transplantation of plasma concentrates and fat granule can significantly improve the early survival rate of fat cells[13].

Table 1 Mean increase (cm) of the nipple plane after CGF-fatty granule complex breast augmentation

Figure 1 Case 1,female,32 years old,comparation of breasts before and half a year after CGF and autologous fat granule mixture injecting operation.Note:① Front side before operation;② Front side half a year after operation;③ Flank side before operation;④ Flank side half a year after operation

Figure 2 Case 2,female,43 years old,comparation of breasts before and half a year after CGF and autologous fat granule mixture injecting operation.Note:① Front side before operation;② Front side half a year after operation;③Flank side before operation;④Flank side half a year after operation

Through retrospective analysis of 43 cases of beauty seekers experienced fat transplantation with PRP and facial autologous,Heping Huang et al.[14]found that PRP can improve the survival rate of postoperative transplanted fat,and the facial filling effect was good.In recent years,some scholars[15]combined PRP with autologous fat transplantation for breast augmentation in 36 cases,the average increase in chest circumference at 6 months and 12 months after operation was 4.38cm and 3.45cm,respectively.Also,the breast shape was significantly improved after operation.However,PRP also has shortcomings.For example,its preparation process is relatively tedious because the addition of substances such as thrombin and CaCl2 is necessary,and the risk of infection still exists.In 2006,L Sacco first obtained the third-generation platelet-concentrating growth factor CGF through continuous differential centrifugation by using a special centrifuge.Comparing with PRF,the preparation of CGF was simpler,and it has a tougher fibrin structure and higher concentration of growth factor and CD34 positive cells.A study found that CGF has positive effects on bone regeneration,wound healing,tissue regeneration,etc.[7].

This study collected 28 female beauty seekers from May 2015 to June 2018 in our hospital.Breast augmentation through the combination of CGF and autologous fat transplantation was performed.All patients were followed up for 1 year.In a total of 28 cases,the patients’ breasts were significantly enlarged.The effect of the second operation is more obvious than the first time:the breast is naturally shaped and soft to touch.The sizes of breasts are stable,and the skin elasticity is improved.Thus,the operational effect is quite satisfactory.No complications such as infection,hematoma,and breast callosity occurred.Also,no loculated cystic effusions were found in the breast color Doppler ultrasound examination.After operations,the author summarized the precautions as following:(1) Selecting negative-pressure manual liposuction would cause less damage to fat cells and is conducive to the survival of fat cells;(2) The rinsing of extracted fat granule,lidocaine and adrenaline can influence the survival of fat[16],and thus,the whole operation process must be aseptic;(3) While filling the breast with granular fat,injection into the mammary gland should be avoided,and the fat at all layers should be injected evenly and slowly,following the principle of“multiple points,multiple tunnels,and multiple levels of slight injection”[17]in order to ensure the even distribution of fat granule and maximum of the implantation area;special attention should be paid under the dermis,and a proper amount of fat ought to be transplanted to obtain better results.

This study combined CGF and autologous granule fat for breast augmentation for the first time,the results showed good operation effect.Not only the surgical damage was small,but also the double effect of body slimming and breast enlargement was accomplished.The problem of high absorption and necrosis of fat transplantation was resolved because of the addition of concentrated cell growth factor.Also,the fat survival rate was increased,and the postoperative complications were reduced.Of course,the survival rate of CGF-autologous fat granule remains to be further researched by conducting control studies.To conclude,compared with the prosthetic breast augmentation and simple fat-filled augmentation,the CGF augmentation has unique advantages.Thus,it will be more and more popular with patients with breast augmentation needs.Besides,it also plays an important role in facial rejuvenation and wound repair.

ACKNOWLEDGEMENTS

The author would like to thank Hefei for the support of key medical disciplines construction.

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