**7. Abdominal contouring**

Our algorithm for abdominal contouring is simple. It pivots on four determining factors.

The first factor is the skin quality, laxity and excess. The second the rectus sheath its weakness, bulge, divarication and any hernia/s. The third is fat, its excess and distribution. The fourth is patients' aspirations and whether they are achievable, if so, how best to achieve them safely and efficiently.

If the skin quality is poor with laxity and significant excess, then a surgical excision is warranted (**Figure 6**). If the rectus sheath shows weakness with bulge and divarication, a plication is required. If a hernia is detected on ultrasound prior to surgery, then a multidisciplinary repair of this hernia with a general surgeon is planned.

Fat excess warrants liposculpture; however, the fat distribution influences the way we create curves and the time it takes. Patients' aspirations will have an influence on us as plastic surgeons; however, we must respect the confines of what is scientifically achievable within the realms of safety yet obtaining the best aesthetic results.

We must on occasions when a patient has unrealistic expectations protect that patient by being honest with them. Although we let them down gently, however, we will offer them the reasoning as to why and the support required.

Abdominoplasty with rectus sheath plication is a common procedure. Our aspirations and goals are to push the surgical outcomes of abdominoplasty to new heights. This is achievable when the aesthetic results of surgery; significantly outweighs the size of scarring whilst creating the desired contours and appropriate proportions. To do so, an open mind utilising a hybrid approach must be contemplated (**Figures 7** and **8**).

As plastic surgeons we aspire to always better our surgical outcomes and improve safety. Understanding the abdominal vascular territories and blood supply meant we could incorporate liposculpture with surgical excision yet reduce surgical complications [18].

#### **Figure 6.**

*Forty-nine-year-old female 6 months following VASER liposculpture to abdomen and flanks with abdominoplasty and plication of the rectus sheath. She also had bilateral breast reduction with fat transfer to upper poles to improve upper pole fullness.*

#### **Figure 7.**

*Forty-three-year-old female 6 months following 360 VASER liposculpture of abdomen and flanks with first stage fat transfer to breasts. Followed by a second stage VASER liposculpture of thighs and back.*

#### **Figure 8.**

*Forty-three-year-old female 6 months following 360 VASER liposculpture of abdomen, and flanks with first stage fat transfer to breasts. Followed by a second stage VASER liposculpture of thighs and back.*

VASER has added a safety margin to abdominoplasty as it produces less traumatic fat removal from the abdominal flap, thus decreasing the chances of complications associated with lipo-abdominoplasty [19].

Suction-assisted liposuction does not impair the regenerative potential of adiposederived stem cells [20]. As the lipo-aspiration pressures are much lower following VASER than traditional liposuction, this also reduces risks to the skin [21].

The Vent-X, which is the vacuum pump designed to work with VASER, the vacuum it generates ranges from 0 to 760 mmHg. The dial starts at zero and goes all the *Body Contouring and VASER Technology, the Fourth Dimension DOI: http://dx.doi.org/10.5772/intechopen.108935*

way to 30. If we are to perform lipo-aspiration with fat transfer in mind, then we set the dial at 10–12, which equates to a third of atmosphere, ~250 mmHg. In doing so, we protect the skin and the harvested fat [21]. VASER also reduces surgeon's fatigue as the more fluid fat the easier it is to aspirate.

The time it takes from fat harvest to fat transfer has a bearing on the retention of fat in the recipient site. The shorter the time, the better the uptake with a critical period of 2 hours [22]. With VASER making fat harvest more time-efficient, this could further aid in better fat retention.

We must consider whether there is a limit of the lipoaspirate volume when performing an abdominoplasty; however, overall, the literature appears to support that current limits on liposuction volumes in lipo-abdominoplasty are arbitrary and do not reflect valid thresholds for increased complications in the hands of an experienced plastic surgeon [23].

#### **8. Breast contouring**

Accepting when we think of the word breast/s contouring does not normally stem to mind. When talking about breast contouring in the majority, we tend to focus on augmentation, reduction, mastopexy and mastopexy augmentation. However, if we go back to the basics, the word contouring is to change the shape of something, hence by changing the shape of the breast/s we are effectively contouring them [24–26].

Fat transfer to the breasts has become popularised following a change in the views about its safety by the American Society of Plastic Surgeons in 2009. It was more than two decades when they condemned this procedure due to fear that it may obscure the detection of breast cancer [24–26].

In this section, we will focus on breast contouring and fat transfer in the context of autogenous augmentation, mastopexy augmentation, asymmetry correction, and volume replacement (**Figure 9**).

The hybrid approach, which includes silicone implants with fat transfer, will also be considered. In selected patients, fat transfer is performed at the same time as breast reduction surgery; thus, adding fullness to the upper poles and cleavage of the breasts (**Figure 6**).

We must accept that not all patients desire one or the other treatment/s and fat is not always available to achieve the goals set out in the agreed pre-treatment planning schedule.

Considerations when injecting fat in the breasts include targeting the subcutaneous space and pre-pectoral plane, in addition to the breast tissue. Respecting the views of others and their practices, however, we do not see a case for transferring fat into or under the pectoral muscles and feel that this could add unnecessary risks without necessarily improving the aesthetic outcomes.

It is important to keep in mind that the pre-operative breasts' volume has an influence on the volume that ought to be transferred. Hence, it is important to appropriately counsel the patients prior to treating them as fat resorption will occur and can vary between 30 and 70% of the transferred volume within 12 months of transfer [27].

In females who are undergoing fat transfer to the breasts, we include a routine mammogram as a baseline in patients ≥40 years of age. As an added safety net, we routinely perform abdominal ultrasound screening if we are using the abdomen as a fat donor site to exclude any clinically undetected hernias and rectus sheath pathology or abnormal anatomy.

#### **Figure 9.**

*Thirty-year-old female. She had VASER liposculpture to abdomen. She had 340 cc of fat transferred to right breast and 220 cc to left breast for the purpose of asymmetry correction and augmentation.*

Surgical fat transfer techniques include three steps, fat harvest, processing the harvested fat and finally injecting it into the breast/s [28].

The volume of fat required influences the technique for fat harvesting. Early on we used a syringe-based mechanical aspiration of the fat and the Coleman centrifuge [29].

However, we now use Vaser for the larger volume fat harvest with a 3.7 mm cannula. Our technique includes allowing the aspirated fat to self-separate over a period of 30 minutes rather than spinning it with centrifuge, as we believe this reduces the trauma to the harvested fat.

The fat is then injected into the breasts using a 10 cc syringe and 2 mm cannula. For further refinement, a 5 or 1 cc syringe can be used when required.

Although the literature supports the view that when using the larger harvest cannula, the more fat survives. Nonetheless, a balance must be struck between cosmetic outcomes and scarring extent [30].

Our experience tells us like others that the less we handle the fat, the better is the survival rate when transferred into other tissues [31].

It is important to add that it is best to transfer the fat without significant time delay from the time it was harvested and to use a closed system when harvesting the fat with the least exposure to air [32].

The fat must be infused with small volume injections and distributed in different levels of the breast with the least traumatic method using a retrograde injection technique to minimise injections into vascular spaces. We aspire to limit the fat transfer volume per breast to 250–300 cc (**Figures 6** and **7**).

If larger volume of fat is required for transfer in a small breast, then pre-surgery external expansion is recommended [33]. However, in our practice and contrary to the experience of others we find uptake and acceptance for this method of external expansion amongst our patients thus far has been very limited.
