Autologous fat is a versatile, useful medium with untold potential applications in cosmetic surgery. It is ideal for filling soft tissue defects, providing quick, economical, and adaptable augmentation without provoking immune rejection or granuloma as occurs with non-autogenous materials. We use the phrase “bra strap shoulder-pitting defect” to refer to a hollowing or crevice that commonly forms in the shoulder area underlying a woman’s bra straps. The rigorous task of lifting and supporting pendulous, heavy breasts over the course of many years, or prolonged use of narrow bra straps tends to focus the weight-bearing load at the upper ridge of the shoulder, causing a permanent pitting defect in the adipose. Several of our patients felt self-conscious of these indentations and requested a surgical remedy. Autologous fat cells were harvested and used to fill the shoulder defects, restoring a beautiful contour with permanent, highly satisfactory results. We present this procedure as a novel autograft technique.
INTRODUCTION:
In our youth-obsessed culture, the expression “aging gracefully” is becoming increasingly synonymous with “plastic surgery,” and visible clues to a woman’s natural age occasionally invoke distress and embarrassment. Wrinkly hands, withered lips, and bra strap-pitted shoulders announce the unmistakable progression of advancing years. Happily, these blemishes can be erased away using the very thing our patients hate most, the dreaded F-word — “fat” (which is, incidentally, uttered as vehemently as the equally dreaded G-word – “geriatric”, a description many beautiful and amazingly young-looking women would rather avoid). Fortunately, overnight restoration of the elegant décolletage is possible with free fat transfer.
Autologous fat graft techniques have advanced considerably since they were first developed in 1893, allowing for the cosmetic reversal of telltale signs of age including wrinkles, nasolabial folds, and other soft tissue flaws. However, a good result depends on successful graft “take”, which hinges upon the survival of delicate adipose cells. This survival rate has been improved immensely through modernization of harvesting techniques, fat handling after removal, centrifuge speed and time, and re-implantation procedures.[1] Other variables such as the patient’s metabolism and health, smoking, and graft site aftercare are pertinent to cell survival, and should also be taken into consideration. Our technique, employing autografts to fill the bra strap shoulder pit defect, is described in greater detail below.
METHODS & MATERIALS:
A careful review of the procedure, pre- and post-operative care, and possible adverse reactions should be discussed with the patient. Photographic documentation is important in planning and for follow-up.
Pre-op
The patient is marked, outlining both the defect and the harvest site. Local anesthetic is injected to anesthetize the skin. Generally, we use a 22 or 25-gauge spinal needle to infiltrate the donor area with tumescent fluid, which consists of 1 mm of epinephrine, 50 mg of lidocaine, and 500 cc of normal saline.
Harvesting and Transfer
Approximately 5 minutes after infiltration, the donor site is suctioned by hand with a 10 cc syringe, using mild suction (<0.5 atm) and a gentle motion for aspiration to preserve cell membrane integrity.
If the fat does not come out readily, we generally move to another area. The sample is left in the syringe to be centrifuged, and then injected, with little or no transfer. It is important to keep in mind that trauma inflicted to fragile adipocytes will damage the graft’s ultimate viability and “take”. Attempting harvests in donor areas where the fat is difficult to remove will likely damage the structural integrity of cells, causing membrane rupture and cell necrosis.
A blunt tipped cannula is used for fat graft injection. This helps to avoid injecting directly into blood vessels. The cannula is inserted into the bra strap defect/ recipient site and pushed forward to create a tunnel. “Threading” or slow withdrawal of the cannula while the fat is distributed into this canal allows for a gentle and atraumatic delivery of the donor cells. Layering these filled tunnels in a deep-to-superficial, criss-cross pattern reduces irregularity and provides the smoothest result. We recommend 20-40% overcorrection to compensate for residual liquid within the graft and the likelihood of adipocyte necrosis, factors which might otherwise cause some reappearance of the bra strap shoulder defect over time.
Post-op
The patient is asked to wear a sports-type bra for the next 2 months, avoiding bras with straps or heavy backpacks that focus weight-bearing pressure on the recipient sites. This helps to preserve delicate graft cells in the critical post-transfer period.
DISCUSSION:
Autologous fat graft is a fast, inexpensive and long-lasting method of restoring the contours of a youthful female décolletage to patients with permanent bra strap indentations, with a low risk of adverse reactions. Possible complications are those associated with any fat transfer procedure, and include resorption, unevenness, distortion, infection, undergrafting and overgrafting.
The area of the shoulder where this fat graft is performed is well-vascularized and not particularly mobile. Thus, we have achieved excellent results without losing an excessive percentage of cells to resorption or requiring multiple grafting sessions.
The adipocyte is basically a tiny drop of oil enclosed in a weak, transparent membrane. Negative pressure in the syringe acts directly upon cell membranes. Increasing the power suction from negative 0.5 atmospheres to 0.95 atmospheres results in membrane rupture and vaporization of fat cells. Vigorous washing or straining of centrifuged material may easily damage the fragile cells, subsequently reducing the viability of the graft. A successful harvest technique will protect and preserve the adipocyte structural integrity as much as possible. Furthermore, the harvest site should be readily accessible, free of scar and fibrous tissue, and the fat removed in a symmetrical fashion. Uni- or bilateral correction of the bra strap shoulder-pitting defect involves these technical considerations.
CONCLUSION:
For some, self-esteem in the face of obvious bodily aging is difficult to maintain. Going to the beach, wearing a certain dress or even buying clothing may become emotionally draining exercises when mired in self-conscious embarrassment. Fixation upon some perceived bodily flaw, such as bra strap shoulder indentions, may aggravate a needless sense of shame and disappointment. Thus, our patients were happily relieved to discover that their shoulders, permanently pitted after years of bra strap tension and weight-bearing, could be easily restored to a perfect, beautiful contour with one brief 30-minute fat grafting session. Fat autograft is a quick, permanent and ideal remedy for this cosmetic defect.
REFERENCES:
1. Mentz H, Ruiz-Razura A, Mentz G. Indications for Fat Grafting in Plastic Surgery. Plastic Surgery Products