per operation, per breast. the pre-procedure mammograms were negative for malignant neoplasms. in the 17-patient cohort, it was noted that two women developed breast cancer (diagnosed by mammogram) post-procedure: one at 12 months, and the other at 92 months. further, the study cell-assisted lipotransfer for cosmetic breast augmentation: supportive use of adipose-derived stem/stromal cells (2007), an approximately 40-woman cohort indicated that the inclusion of adipose stem cells in the grafts of adipocyte fat increased the rate of corrective success of the autologous fat-grafting procedure. fat harvesting and contouring the centrifugal refinement of the liposuction-harvested adipocyte tissues removes blood products and free lipids to produce autologous breast filler. the injectable filler-fat is obtained by centrifuging (spinning) the fat-filled syringes for sufficient time to allow the serum, blood, and oil (liquid fat) components to collect, by density, apart from the refined, injection-quality fat. to refine the fat for facial injection quality, the fat-filled syringes are centrifuged for 1.0 minute at 2,000 rpm, which separates the unnecessary solution, leaving refined filler-fat. moreover, centrifugation at 10,000 rpm for 10 minutes produces a "collagen graft"; the histologic composition of which is cell residues, collagen fibres, and 5.0 percent intact fat cells. furthermore, because the patient's body naturally absorbs some of the fat grafts, the breasts maintain their contours and volumes for 18–24 months. fat-graft breast augmentation: the pre-operative aspects (left) and the post-operative aspects (right) of a large-volume non-surgical augmentation in the study fat grafting to the breast revisited: safety and efficacy (2007), the investigators reported that the autologous fat was harvested by liposuction, using a 10-ml syringe attached to a two-hole coleman harvesting cannula; after centrifugation, the refined breast filler fat was transferred to 3-ml syringes. blunt infiltration cannulas were used to emplace the fat through 2-mm incisions; the blunt cannula injection method allowed greater dispersion of small aliquots (equal measures) of fat, and reduced the possibility of intravascular fat injection; no sharp needles are used for fat-graft injection to the breasts. the 2-mm incisions were positioned to allow the infiltration (emplacement) of fat grafts from at least two directions; a 0.2 ml fat volume was emplaced with each withdrawal of the cannula. the breasts were contoured by layering the fat grafts into different levels within the breast, until achieving the desired breast form. the fat-graft injection technique allows the plastic surgeon precise control in accurately contouring the breast – from the chest wall to the breast skin envelope – with subcutaneous fat grafts to the superficial planes of the breast. this greater degree of breast sculpting is unlike the global augmentation realised with a breast implant emplaced below the breast or below the pectoralis major muscle, respectively expanding the retromammary space and the retropectoral space. the greatest proportion of the grafted fat usually is infiltrated to the pectoralis major muscle, then to the retropectoral space, and to the prepectoral space, (before and behind the pectoralis major muscle). moreover, although fat grafting to the breast parenchyma usually is minimal, it is performed to increase the degree of projection of the bust. fat-graft injection the biologic survival of autologous fat tissue depends upon the correct handling of the fat graft, of its careful washing (refinement) to remove extraneous blood cells, and of the controlled, blunt-cannula injection (emplacement) of the refined fat-tissue grafts to an adequately vascularized recipient site. because the body resorbs some of the injected fat grafts (volume loss), compensative over-filling aids in obtaining a satisfactory breast outcome for the patient; thus the transplantation of large-volume fat grafts greater than required, because only 25–50 percent of the fat graft survives at 1-year post-transplantation. the correct technique maximizes fat graft survival by minimizing cellular trauma during the liposuction harvesting and the centrifugal refinement, and by injecting the fat in small aliquots (equal measures), not clumps (too-large measures). injecting minimal-volume aliquots with each pass of the cannula maximizes the surface area contact, between the grafted fat-tissue and the recipient breast-tissue, because proximity to a vascular system (blood supply) encourages histologic survival and minimizes the potential for fat necrosis. transplanted autologous fat tissue undergoes histologic changes like those undergone by a bone transplant; if the body accepts the fat-tissue graft, it is replaced with new fat tissue, if the fat-graft dies it is replaced by fibrous tissue. new fat tissue is generated by the activity of a large, wandering histocyte-type cell, which ingests fat and then becomes a fat cell. when the breast-filler fat is injected to the breasts in clumps (too-large measures), fat cells emplaced too distant from blood vessels might die, which can lead to fat tissue necrosis, causing lumps, calcifications, and the eventual formation of liponecrotic cysts. fat-graft breast augmentation: the pre-operative aspects (left) and the post-operative aspects (right) of a medium-volume non-surgical augmentation the operating room time required to harvest, refine, and emplace fat to the breasts is greater than the usual 2-hour or time; the usual infiltration time was approximately 2-hours for the first 100 cm3 volume, and approximately 45 minutes for injecting each additional 100 cm3 volume of breast-filler fat. the technique for injecting fat grafts for breast augmentation allows the plastic surgeon great control in sculpting the breasts to the required contour, especially in the correction of tuberous breast deformity. in which case, no fat-graft is emplaced beneath the nipple-areola complex (nac), and the skin envelope of the breast is selectively expanded (contoured) with subcutaneously emplaced body-fat, immediately beneath the skin. such controlled contouring selectively increased the proportional volume of the breast in relation to the size of the nipple-areola complex, and thus created a breast of natural form and appearance; greater verisimilitude than is achieved solely with breast implants. the fat-corrected, breast-implant deformities, were inadequate soft-tissue coverage of the implant(s) and capsular contracture, achieved with subcutaneous fat-grafts that hid the implant-device edges and wrinkles, and decreased the palpability of the underlying breast implant. furthermore, grafting autologous fat around the breast implant can result in softening the breast capsule. external tissue expansion the successful outcome of fat-graft breast augmentation is enhanced by achieving a pre-expanded recipient site to create the breast-tissue matrix that will receive grafts of autologous adipocyte fat. the recipient site is expanded with an external vacuum tissue-expander applied upon each breast. the biological effect of negative pressure (vacuum) expansion upon soft tissues derives from the ability of soft tissues to grow when subjected to controlled, distractive, mechanical forces. (see distraction osteogenesis) the study reported the technical effectiveness of recipient-site pre-expansion. in a single-group study, 17 healthy women (aged 18–40 years) wore a brassiere-like vacuum system that applied a 20-mmhg vacuum (controlled, mechanical, distraction force) to each breast for 10–12 hours daily for 10 weeks. pre- and post-procedure, the breast volume (size) was periodically measured; likewise, a magnetic resonance image (mri) of the breast-tissue architecture and water density was taken during the same phase of the patient's menstrual cycle; of the 17-woman study group, 12 completed the study, and 5 withdrew, because of non-compliance with the clinical trial protocol. the breast volume (size) of all 17 women increased throughout the 10-week treatment period, the greatest increment was at week 10 (final treatment) – the average volume increase was 98+/–67 percent over the initial breast-size measures. incidences of partial recoil occurred at 1-week post-procedure, with no further, significant, breast volume decrease afterwards, nor at the follow-up treatment at 30-weeks post-procedure. the stable, long-term increase in breast size was 55 percent (range 15–115%). the mri visualizations of the breasts showed no edema, and confirmed the proportionate enlargement of the adipose and glandular components of the breast-tissue matrices. furthermore, a statistically significant decrease in body weight occurred during the study, and self-esteem questionnaire scores improved from the initial-measure scores. because external vacuum expansion of the recipient-site tissues permits injecting large-volume fat grafts (+300 cc) to correct defects and enhance the bust, the histologic viability of the breast filler (adipocyte fat) and its volume must be monitored and maintained. the long-term, volume maintenance data reported in breast augmentation using pre-expansion and autologous fat transplantation: a clinical radiological study (2010) indicate the technical effectiveness of external tissue expansion of the recipient site for a 25-patient study group, who had 46 breasts augmented with fat grafts. the indications included micromastia (underdevelopment), explantation deformity (empty implant pocket), and congenital defects (tuberous breast deformity, poland's syndrome). pre-procedure, every patient used external vacuum expansion of the recipient-site tissues to create a breast tissue matrix to be injected with autologous fat grafts of adipocyte tissue, refined via low g-force centrifugation. pre- and post-procedure, the breast volumes were measured; the patients underwent pre-procedure and 6-month post-procedure mri and 3d volumetric imaging examinations. at six months post-procedure, each woman had a significant increase in breast volume, ranging 60–200 percent, per the mri (n=12) examinations. the size, form, and feel of the breasts was natural; post-procedure mri examinations revealed no oil cysts or abnormality (neoplasm) in the fat-augmented breasts. moreover, given the sensitive, biologic nature of breast tissue, periodic mri and 3-d volumetric imaging examinations are required to monitor the breast-tissue viability and the maintenance of the large volume (+300 cc) fat grafts. post-mastectomy procedures surgical post-mastectomy breast reconstruction requires general anaesthesia, cuts the chest muscles, produces new scars, and requires a long post-surgical recovery for the patient. the surgical emplacement of breast implant devices (saline or silicone) introduces a foreign object to the patient's body (see capsular contracture). the tram flap (transverse rectus abdominis myocutaneous flap) procedure reconstructs the breast using an autologous flap of abdominal, cutaneous, and muscle tissues. the latissimus myocutaneous flap employs skin fat and muscle harvested from the back, and a breast implant. the diep flap (deep inferior epigastric perforators) procedure uses an autologous flap of abdominal skin and fat tissue. post-mastectomy fat-graft reconstruction the reconstruction of the breast(s) with grafts of autologous fat is a non-implant alternative to further surgery after a breast cancer surgery, be it a lumpectomy or a breast removal – simple (total) mastectomy, radical mastectomy, modified radical mastectomy, skin-sparing mastectomy, and subcutaneous (nipple sparing) mastectomy. the breast is reconstructed by first applying external tissue expansion to the recipient-site tissues (adipose, glandular) to create a breast-tissue matrix that can be injected with autologous fat grafts (adipocyte tissue); the reconstructed breast has a natural form, look, and feel, and is generally sensate throughout and in the nipple-areola complex (nac). the reconstruction of breasts with fat grafts requires a three-month treatment period – begun after 3–5 weeks of external vacuum expansion of the recipient-site tissues. the autologous breast-filler fat is harvested by liposuction from the patient's body (buttocks, thighs, abdomen), is refined and then is injected (grafted) to the breast-tissue matrices (recipient sites), where the fat will thrive. one method of non-implant breast reconstruction is initiated at the concluding steps of the breast cancer surgery, wherein the oncological surgeon is joined by the reconstructive plastic surgeon, who immediately begins harvesting, refining, and seeding (injecting) fat grafts to the post-mastectomy recipient site. after that initial post-mastectomy fat-graft seeding in the operating room, the patient leaves hospital with a slight breast mound that has been seeded to become the foundation tissue matrix for the breast reconstruction. then, after 3–5 weeks of continual external vacuum expansion of the breast mound (seeded recipient-site) – to promote the histologic regeneration of the extant tissues (fat, glandular) via increased blood circulation to the mastectomy scar (suture site) – the patient formally undergoes the first fat-grafting session for the reconstruction of her breasts. the external vacuum expansion of the breast mound created an adequate, vascularised, breast-tissue matrix to which the autologous fat is injected; and, per the patient, such reconstruction affords almost-normal sensation throughout the breast and the nipple-areola complex. patient recovery from non-surgical fat graft breast reconstruction permits her to resume normal life activities at 3-days post-procedure. the breast mound the breast-tissue matrix consists of engineered tissues of complex, implanted, biocompatible scaffolds seeded with the appropriate cells. the in-situ creation of a tissue matrix in the breast mound is begun with the external vacuum expansion of the mastectomy defect tissues (recipient site), for subsequent seeding (injecting) with autologous fat grafts of adipocyte tissue. a 2010 study, reported that serial fat-grafting to a pre-expanded recipient site achieved (with a few 2-mm incisions and minimally invasive blunt-cannula injection procedures), a non-implant outcome equivalent to a surgical breast reconstruction by autologous-flap