"I believe that structural fat
grafting is going to revolutionize breast surgery and completely change the way
plastic surgeons deal with the female breast."
But one thing is very clear -- you're going to be hearing a lot more about the
procedure which is also known as structural fat grafting, Lipotransfer,
microlipoinjection and autologous fat
-- Sydney Coleman, M.D.
New York City's Sydney
Coleman, M.D., a board certified plastic surgeon and clinical associate
professor, is widely regarded as the world's leading proponent, researcher and
provider of breast enlargement via fat transfer. While his own version of fat
grafting is trademarked as LipoStructure, virtually all surgeons worldwide who
successfully employ fat grafting use his technique or a variant of it.
To shed some light on a seemingly confusing topic, CosmeticSurgery.com sat
down with Dr. Coleman for an interview about the current state of fat grafting
for breast enlargement.
QUESTION: When did the controversy about fat transfer to the breast start?
ANSWER: Some plastic surgeons have been transplanting fat to the breast for a
century, although it was not widely performed. In the 1980s, after liposuction
gave surgeons a convenient source for fat, more started offering it but the
results were not always the same. In 1995, I started grafting fat to the breast.
Q: Is that why so many surgeons say fat grafting is just injecting
dead fat cells?
A: Human fat is incredibly delicate -- at least, outside the human body. Unless
donor fat is prepared with the greatest care in a very particular manner, it
will not survive. And it must be placed back in the patient in a certain manner
and also with great care or it will not find a blood supply and live.
Q: What does fat
A: Donor fat has to be removed with much more care than in an ordinary
liposuction. The surgeon can't use high-powered suction equipment or a
the wand inserted into the pockets of fat. Nor can the cannula be too wide. Once
the aspirate --that is, the combined fluids taken from the body during fat
removal -- is collected, fat cells must be separated from the other fluids like
oil, blood, saline and medicines used in the procedure. Fat cells are usually
filtered and separated with a centrifuge but, again, the centrifuge can't whirl
too fast or be too big least it kill the cells.
In fact, to facilitate the entire process, I invented some kinder, more
benign surgical tools appropriate to gentle fat collection and deposit. For
instance, I use a blunt instrument to insert fat cells to avoid injury to nerves
and blood vessels.
The fat must be placed in dozens of layers throughout the breast in very tiny
drops. And that takes a lot of time and tremendous attention to detail.
Q: Why the tiny drops? That must be excruciatingly painstaking.
A: It is, but there is no way around it. If the drops of fat cells are placed
near muscle and fat tissue in many different layers of the breast, most of the
cells will develop a blood supply, thrive and become a part of the breast.
Painstaking? Consider this: it takes 25 passes to deposit a teaspoon of purified
fat cells. To put in a cup of fat cells requires 1250 passes. My fastest breast
augmentation using this method has been four hours while the longest has taken
six or seven hours. A surgeon just can't squirt a huge amount of fat cells into
a breast and expect it to survive
Q: How many of the fat cells DO survive?
A: The survival of fat cells depends on the technique used, the surgeon's
experience, the areas grafted and the individual patient's response. Some
surgeons using my techniques report about 80 percent survival rate.
Q: Why is fat transfer a better way to enlarge breasts instead of using
silicone or saline implants?
A: Many reasons. Fat is your own natural tissue and can't be rejected. Implants
can leak, show and protrude through the skin, cause scarring and even cause the
breast to droop. If you have a breast implant, you will at some point in your
life have at least one more operation to replace or remove them. However, in fat
grafting, minimal incisions are used. The surgeon can sculpt and shape the
breasts for a completely natural look and feel. For instance, with fat grafting,
I can create tear-drop shaped breasts with nipples that do not point down. Or, I
can create a natural looking cleavage or make the breasts flow smoothly and
naturally into the armpits. You don't see that with saline or silicone implants.
A 28-year-old-patient with tubular
breast deformity, left, received fat grafting to the breast on two
occasions. The right picture shows how she looked four years and 11 months after
the second fat grafting. She had a total of 720 cc’s (a little over three
measuring cups) of fat transferred into the right breast and 670 cc’s (about 2.8
cups) into the left.
Q: What are the downsides? What do you disclose to your patients
about fat grafting to the breast?
A: Besides the normal risks of any surgery like possible infection, I tell
patients the procedure takes longer; it takes several months before the final
results can be seen; the maximum increase in one session is one cup size; that
some fat may be absorbed by the body and that very thin patients may not have
enough donor fat to spare.
Q: Then why are the largest professional plastic surgery societies -- the
ASPS and ASAPS -- cautioning consumers against having the procedure?
A: It stems from a 1987 ASPS position paper that predicted fat grafting would
conceal breast cancer detection and should therefore be prohibited. After 1987,
nobody in the United States or the world spoke of fat grating to the breast
until 2005. There is a huge prejudice against fat grafting in general among the
plastic surgeons who have tried it -- using their own particular method -- and
failed. These surgeons judge fat grafting by the failures, choosing to ignore or
even ridicule others' successes. It is extremely easy to kill fat and they have
succeeded admirably in their efforts.
Q: How could fat grafting conceal breast cancers?
A: If transplanted fat dies, it leaves some scarring and calcification. Mind
you, there have been no studies on enlarged breasts via fat transfer to prove
it, but the opinion of one ASPS committee at the time was that calcification
could confuse breast
cancer tests and delay or prevent
treatment. That has pretty much discouraged other practitioners and research for
the last 20 years. Oddly enough, research done that same year -- 1987 -- shows
that, within two years of breast reduction surgery, 50 percent of the patients'
mammograms showed calcifications. But nobody suggested doing away with the
Q: Have things changed since '87?
A: Mammogram screens and X-rays are now much more sensitive. Radiologists are
usually confident about being able to distinguish the calcifications caused by
dead fat from calcifications indicating breast cancer. If they have any doubt,
radiologists also have tools like ultrasound and MRI's to further aid them.
Q: What should be done next?
A: We should encourage standardized procedures for fat grafting to the breast.
Currently, virtually every surgeon doing the procedure separates the fat cells
from the aspirate differently. And our very first concern, even before creating
beautiful, larger breasts, is patient safety. Moreover, we should ensure those
patients undergo regular mammography and do breast self-exams. And, we also want
to prevent unnecessary biopsies. My biggest concern is technique -- my greatest
fear is that some practitioners will still squirt large amounts of fat cells
into breasts. Such a glob of transplanted fat will never find a blood supply and
survive. The problem is not that the glob will die, but that it will live
unevenly and may create irregularities and lumps.
Q: Where else is breast enlargement with the patient's own fat being done?
A: I started discussing fat grafting to the breast in France and Italy about ten
years ago so they have been using the technique to enlarge breasts much longer
than in the United States. Last year, the French Society of Plastic Surgery at
their annual meeting presented ten medical articles on fat grafting to the
breast. In most of the world, especially, France and Korea, if a surgeon is
grafting fat successfully any place in the body, he or she is using the "Coleman
technique." But U.S. surgeons seemed to have dropped my name, even though
they use my technique.
Q: Can fat grafting be applied to other sections of the body?
A: Absolutely. In fact, I started this work twenty years ago, doing buttocks
augmentation and filling in the
little divots in the body caused during some liposuction procedures. The same
technique of taking and preparing donor fat and adding it drop by tiny drops in
buttocks is now being done by perhaps a dozen U.S. surgeons
who create rounder, shapelier derrières for
transfer to the hand and face is
a widely accepted procedure; fat grafting is additionally used to smooth out the
rough edges of breast implants that show through the skin and to create
cleavages. Structural fat grafting can also be used to correct many craniofacial
and maxilla facial deformities such as lip deformities after cleft lip repairs.
Q: Why are you regarded as the leader in the field?
A: Most physicians showing long term fat transfer survival rates are using my
technique; I have given many three-day courses with video or live demonstrations
and short instruction courses several times a year all over the world. I've
published about 25 scientific articles on fat grafting to the breast and allow
other surgeons to come in and observe my techniques.
Q: What is the bottom line, doctor? Where is all this headed?
A: I believe that structural fat grafting is going to revolutionize breast
surgery and completely change the way plastic surgeons deal with the female
Q: Thank you, Dr. Coleman.
A: You're very welcome.