Autologous fat tissue graft
DEFINITIONS AND PRINCIPLES
Lipostructure, also called lipofilling, fat micro-graft, liposculpture or Coleman’s procedure consists in creating volume or filling up a hollow by using the patient’s fat . Thus, this is the most “natural” or most “bio” filling or volume increasing technique, since the patient’s very own fat tissue is taken through liposuction and then re-implanted by injections.
The use of an autologous graft (taken from the patient) avoids the inconvenient related to intolerance risks that may be encountered with filling products or implants. It is to be noted, though, that the fat volume that is obtained in the end is not that which is re-implanted initially, since the result depends on the collection of the fat graft and on the patient’s health habits.
Lipostructure yields best results when performed on less mobile areas and when using good quality fat, i.e., collected from the patient’s stock . Actually, the good stability thereof, hence its stubborn refusal to reduce when one is trying to lose weight, is then turned into an advantage when it is to be used for fat transplant.
In more mobile areas (e.g. the mouth), the fat graft has proved inadequate due to the high risk of substantial secondary resorption, so that an injection product is preferable in such sites. These areas, it is observed, are naturally poor in fat and are probably also poor receivers.
The technique requires:
• local anaesthesia of the collection site as well as of the receiving site (more potent anaesthesia will therefore be required in case of multiple receiver and donor sites);
• collection of the fat tissue from one or several locations depending on the quantity of fat needed and available;
• re-implantation through multiple injections, in order to create fine deposit fascicles arranged in a fan-like fashion, as fat does not take in case of a lump deposit.
All the above makes the process more complex to apply than a filling product injection that can be carried out at the doctor office without anaesthesia. Therefore, lipostructure is primarily proposed when the volumes desired are important (e.g. cheekbones or buttocks), or when a liposuction operation or rejuvenation procedure has already been scheduled to take place under anaesthesia (in order not to “waste” the fat that is removed during liposuction or to complete the rejuvenation action).
Cosmetic indications for lipostructure
Treatment of an emaciated-looking face
In time, some thin faces look more and more “skeletal”: important loss of fat at the temples, around the orbit, as well as of the cheek fat. The filling of gaunt areas is here the key to rejuvenation, but the filling must be adapted in order to avoid a “puffed up” look.
If the patient is elderly, the filling treatment may be combined with surgical re-draping of the tissues (lift), but re-draping alone must be avoided at all cost lest a “mummified” appearance should result. This is because the fact of re-stretching the tissues over a significantly gaunt face, always results in accentuating the underlying depressions.
It is to be noted that, except in special cases, lipostructure is not indicated to act on the marked excess skin in order to avoid having to perform a face lift . Actually, for slackened tissues to retrieve a proper tightness important fat volumes would have to be used as filler. The tight skin appearance would be achieved but so would an unnatural “puffed up” look.
Lipostructure is of value in younger subjects to correct certain massive fat losses consecutive to a diet or illness, but of course this supposes that the patient (male or female) has some good quality body excess fat. If the patient has no fat tissue that can be used, or if the areas to be filled are very mobile, he/she will be proposed injection products instead.
Autologous fat grafts are indicated in repair surgery in the following cases:
• treatment of natural soft tissue asymmetry;
• correction of tissue depression consecutive to trauma-associated localized necrosis;
• correction of surface irregularities consecutive to liposuction.
Body volume enhancement
Lipostructure has been used successfully to enhance the buttocks volume, to replenish emaciated hands and, recently, for slight breast volume enhancement.
Flat or drooping buttocks improvement
As regards the buttocks, lipostructure provides for obtaining much more natural looking results than with prostheses, for much less risk. On this subject, please refer to the FAQ article entitled “Buttocks prosthesis”. Of course, the technique supposes that one has an important fat tissue stock because, in this area, the volume has to be increased to some extent for the volume change to be noticeable.
This is conducted very often when an important volume of fat has been removed in the course of surgery (plastic abdominal, liposuction).
This volume is primarily placed in the upper part of the buttocks to lift those perceptibly and also to avoid trauma to the implanted fat tissue cells upon sitting down during the graft collection phase.
“Pulping up” emaciated hands
Fat implants used on the hands provide two benefits:
• Mechanically, the fat deposit fills up the emaciated areas so as to recreate the soft tissues, which have become atrophied with age, and to dissimulate the veins and bone with this regained thickness.
• Biologically, the addition of fat and the healing help improve the skin surface.
It is to be noted that this technique is not always well-adapted because of the risk of fat deposits being apparent under a thin skin. In such cases, using a very fine filler (a filling product) is preferred; it is less visible but more costly. The lipostructure-based filling of emaciated hands is very seldom practiced alone because the procedure is a heavy one, but rather in the course of another operation requiring anaesthesia.
Slight breast volume enhancement : lipomodelling
In France an experimentation conducted by Dr Emmanuel DELAY(Lyon) has made it possible to propose this technique as an alternative to the use of breast implants when moderate volume enhancement is desired.
Technically, it is obviously mandatory for the patient to present sufficiently important localized excess of fat available for the final result to be visible on her breast, (even taking into account post surgery fat resorption). The patient must also accept to submit to at least a twice-repeated procedure, as well as the possibility of unsatisfactory results.
Medically, this slight volume enhancement technique was first solely performed for reconstructive surgery (where it permitted an amazing upturn) and seen as inadvisable for aesthetic purpose since, at medium-term, part of the implanted fat degradation was difficult to differentiate from cancer–related micro-calcifications. Thanks to recent improvements in medical imaging, it is now considered that this process has no more negative consequences on breast cancer detection..
Besides, improvement of fat transfer techniques did ensure a more harmonious distribution of implanted fat, hence reducing the risk of oily cyst formation or of poor fat graft setting (cytostéatonécrose).
Nevertheless, some surgeons worry about potential interactions between the injected fatty tissue and the mammary gland. Hence, the SOFCPRE stated on the26/12/2007 « While waiting for complementary data, the SOFCPRE does not stand safety autologous fat grafting in the mammary gland except for clinical research protocols, involving a specific medium-term and long-term follow-up of patients ».
Even if, to date, we still have no convincing element proving a breast cancer risk increase due to fat injection, there is still a risk for every patient in accordance with her age, familial antecedents, health behaviour…
It is therefore mandatory that candidate for this surgery should understand that every precaution must be taken in order to limit the risk of coincidence between a cancer unexpected arrival and fat injections. In this spirit, patient asking for breasts fat injections commits herself to have a pre-operating detection check-up (mammography, scan and MRI if necessary) performed by a breast imaging expert and, above all, commits herself to have follow-up examinations performed after 1 year, 2 years and even 3 years, if possible by the same expert, and to follow his recommendations (mammography, scan).
You can refer to the page « augmentation mamaire » section, notably regarding therapeutic options
The special case of fat transfers carried out in the mobile areas in the course of Face Recurve® or Face Recurve® Lift procedures.
Face Recurve® in short
As a reminder, clinical, anatomic and radiological studies conducted by the Le Louarn / Buthiau / Buis team have established the repeated facial expression muscle contractions as the primary cause of structural ageing. Gravity only comes into play secondarily on the skin and fat tissues already damaged by the action of the muscles.
Practically, repeat contraction of the face expression muscles leads to progressive retraction thereof even at rest. From curvilinear and long, they turn rectilinear and short, the same having two consequences:
• Fat tissue is expelled from beneath the concavity of the muscle to be transferred laterally toward the surface. Over time, instead of deep-situated important fatty masses under the muscles and of a fine, regular superficial fat layer, the deep masses shrinks and the superficial fat layer becomes irregular. The face develops unbecoming mass volumes malar fat pads, jowls…
• The shortening of the muscle causes paramedian folds to be created: naso-labial folds, hollowed rings under the eyes, the bitterness fold, the fold between the eyebrows and the cervical bands.
Fat deposits increase the visibility of the furrows due to muscles retraction and vice versa.
This process is clearly amplified by certain specific muscle fascicles called age marker fascicles (AMF). These AMF considerably precipitate structural paramedian ageing (rings under the eyes, naso-labial folds, jowls, bitterness folds, cervical bands) while they do not appear to have any functional role apart from this accelerating of structural ageing.
A whole set of medical and surgical techniques have therefore been developed to meet the particularities of structural ageing. These techniques aim at:
• neutralizing the age marker fascicles (using Botulinum toxin and through targeted surgical sections);
• correcting the fat displacement effects (using fillers or fat transfer procedures).
Eventually, a real care strategy has been developed which proposes a treatment for structural ageing at each stage .
- Stage 0 (or preventive) treatment: Toxin Recurving® . Botulinum toxin injections may be proposed to reduce the muscle resting tone and, hence, to prevent the deleterious action of the age marker fascicles. The toxin is used to reduce resting tone without blocking the contraction strength. There is no fixed-expression appearance.
- Stage 1 treatment: Toxin Filler Recurving ® . Again, Botulinum toxin is used for its action on resting tone but also to limit the contraction strength, while filling products are used in moderate volumes to camouflage the areas that have become hollow following fat displacement.
- Stage 2 treatment: Face Recurve® . Targeted surgical procedures are proposed with Face Recurve®. With this new rejuvenation strategy, fat transfer operations are performed to put the fat tissue back to its original place under the muscle, once further shortening of the latter has been stopped through sectioning or weakening of the age marker fascicle.
- Stage 3 treatment: Face Recurve® Lift . Cutaneous re-draping, i.e., lifting is combined with localized Face Recurve® surgery. The taunt or puffed-up look are avoided, since neither traction nor filling are no longer required to erase the sequelae of the pulling action on the face expression muscles.
In its surgical applications, Face Recurve® , as proposed at stages 2 and 3 of structural ageing, localised fat transfer procedures are therefore conducted during the operation in order to correct structural fat displacement. The issue is to put back the fat tissue where it originated from, under the muscle, to restore the latter’s convexity.
The transferred fat survival, i.e., its durability, is good, even in the mobile areas, because either the muscle activity has been stopped by sectioning (bitterness fold, naso-labial fold), or because the fat is not grafted but slid-transferred strip by strip (hollow rings under the eyes).
For more information on the Face Recurve® concept and its practical applications, please refer to the corresponding article.
LIPOSTRUCTURE IN PRACTICE
Practical recommendations before the procedure
Do not come for the procedure too tired, either morally or physically. Keep us informed of any change in your health status or in your psychological state, and don’t forget that a cosmetic operation is never an emergency.
Do not take any medicine liable to promote bleeding in the days prior to the procedure: aspirin, anti-inflammatory drugs, anticoagulants, vitamin E…
You must absolutely postpone any cosmetic operation is you are sick or, if you are a woman, in case you are pregnant on the day of the appointment. It is imperative to fast (no drinking, no eating) for 6 hours prior to the operation.
Do not forget your visit to the anaesthetist and to have the prescribed laboratory tests performed, as well as any additional check ups that may have been asked to pass.
Plan on taking a shower or a bath before registering at the clinic, have your hair clean and, concerning women, do not wear any nail polish or make up. Avoid shaving the areas involved in graft collection or re-injection (risk of germ contamination in case of micro-cuts and, hence, of an infection postoperatively).
If these preoperative recommendations are not respected, the procedure will be cancelled.
When preparing your personal items, DO NOT FORGET YOUR MEDICAL FILE and the fastening device that was prescribed to you for the area to be used for graft collection (antithrombosis stockings or lipopanty), as the case may be.
When possible, do not bring any precious jewellery (or have them put away in the clinic safe with all your valuable belongings before the operation).
If you are wearing contact lenses, dental fixtures or hearing aids, these must be obligatorily removed before the anaesthesia.
Anaesthesia, hospitalization and operation
The procedure takes place at a clinic and can be conducted:
• under assisted local anaesthesia (NLA) in most of the cases;
• under general anaesthesia if the volume of fat to be collected and reinjected is important and if there are many graft collection and reinjection localizations;
• under simple local anaesthesia for highly limited, localized correction.
On an outpatient basis (ambulatory) if the volume to be transferred and/or the treatment localizations are few. Over a one-to-two-night hospitalization if the volume to be transferred is important and/or the liposuction and reinjection concern several areas.
The duration of the procedure varies depending on the number of localizations and the quantity of fat to be collected and rejinjected. It may last 30 minutes (only one collection area) to 2 1/2 hours, but less than one hour on average.
Leaving the clinic
If the procedure was conducted on an outpatient basis:
As a rule, you will leave a few hours after the operation. However, in certain cases (nausea, stress…), it may be preferable for you to remain hospitalized for one night.
Ask a VALID AND RESPONSIBLE person to accompany you. As anaesthetics are euphoriants, do not plan on doing anything requiring attention or using potentially dangerous machinery. If you return by car, YOU MAY IN NO CASE BE DRIVING.
Have someone at home with you. Actually, you should not be getting up without help during the night following the operation, even to go to the bathroom and, even though you may feel perfectly well (anaesthetics may have the same effect as excess alcohol consumption).
Before leaving home, make sure that you have everything you need for your return:
• Have a light meal prepared in advance;
• On your bedside table, have some Arnica 5CH, paracetamol-based pain killer tablets (Dafalgan, Doliprane…), and a bottle of mineral water.
If the procedure is conducted on a inpatient basis:
Plan on having something comfortable to wear and easy to put on. Normally, you may leave the clinic on the day following the operation.
You should know that the time needed for recover after a lipostructure operation (fatigue, pain) is proportionate to the quantity of fat removed and to the number of spots treated (collection and reinjection areas).
At home, during the first days, you must rest a maximum of time and avoid any violent effort. On the other hand, you should walk enough, several times a day, in order to prevent any risk of embolus and phlebitis, and eat sufficiently to allow healing.
Write down near your telephone at home and in your portable phone the private office number 33(0)1 45 53 27 17 and that of the clinic. Do not hesitate to call us if anything worries you. For example, you should warn us if case of fever, oozing, pain or any other symptom possibly troubling you.
Leave from work . Plan to take 3 to 4 days off work, on average, for physical recovery. But it will take 15 to 20 days for the bruises and swellings to fade away. In cases of facial lipostructure, therefore, you will have to adapt your social and professional life accordingly.
Girdles or varicose stockings will be prescribed in certain cases to help re-drape the skin from the graft collection areas. In such a case, these will have to be worn night and day for 8 days, then 10/15 days only during the day.
The sutures used for the collection areas are either resorbable or to be removed 15-20 days after the operation.
Bruises usually persist for 15 to 20 days.
Swelling will be worst on the 3/4 th day postoperatively and then fades progressively.
Scars take 6 to 9 months to become white.
Gymnastic can be resumed 3 weeks to one month after the operation (avoid any early compression on the graft areas).
In most cases, procedures are eventless and the patients are satisfied by the outcome. Nonetheless, before you make your decision, you should know the risks involved and the possible complications.
General risks inherent to any surgical operation: infection, haematoma, abnormal healing and anaesthesia-related risk. (Titre 3)
This could be serious but occurs only exceptionally when the procedure is carried out under normal conditions and when the health care and postoperative recommendations have been heeded . You will thus be asked to wash everyday with soap and water to keep the scars clean, and to follow the prescription concerning antiseptics and oral antibiotics.
This complication is extremely rare with liposuction, except in special pathological cases or in case of intake of some bleeding-causing medicine before or after the operation. Bleeding is seldom severe, except in cases of concurrent coagulation disorders.
Immediately following the cosmetic procedure, any scar may present signs of inflammation or oozing requiring specific local treatment. On the average term, scars may in some cases present abnormal healing: thickening, widening, cheloid-like, which is primarily dependent on the type of skin (more problems with red-haired or black-skin individuals) and on the health habits (cigarette smoking and birth-control pills increase the risk). However, as far as lipostructure is concerned, scars are very short and mostly strategically located, so that the risk can be considered as quite limited.
Anaesthetic techniques and monitoring methods have greatly progressed and safety is optimal when the procedure is conducted outside of any emergency in a healthy person, and when the anaesthetist is a competent person practicing in an authorized institution. However, anaesthesia may induce more or less unexpected reactions in the organism, which can be more or less easy to control; some peri- and postoperative risks and unexpected events inherent to anaesthesia in general therefore subsist. This is why, as far as cosmetic surgery is concerned, it is paramount to meet the anaesthetist prior to the operation and to inform his/her scrupulously of you health condition. Depending on such as well as on the procedure planned, the anaesthetist will assess the anaesthesia-related risks and special precautions to be taken eventually, and will inform you of the same. Should he/she not recommend the operation, his/her decision will be final. Link to General information workup and anaesthetist visit .
Risks connected with any cosmetic surgery: asymmetry, result judged insufficient or exaggerated and necessary alterations.
The tissue reaction during surgery is always specific and remains partly unpredictable. This depends on the how well the patient has followed the doctor’s recommendations, as well on a chance factor. This is why the risks concerning asymmetry, results judged as insufficient or exaggerated and the possible need for alterations are always evoked in the context of cosmetic surgery.
Risks of imperfections involving the graft collection (donor) area
Concerning liposuction, apart the fat cells that are directly aspirated during the procedure, the damaged cells that are not aspirated are progressively eliminated in the postoperative period. This secondary loss of mass volume specific to each patient’s reaction requires that a safety margin be kept during the operation to avoid excessive volume reduction. Moreover, the skin retraction may give rise to surface irregularities. Consequently, localized imperfections may some times be observed without them representing real complications: residual asymmetry, insufficient correction, surface irregularities. These are usually controllable by alteration under local anaesthesia starting on the 6 th month after the operation.
Waves are the most commonly encountered problem. They are caused by poor skin retraction or liposuction performed too closely to the skin. The best way to prevent those is to remove reasonable amounts of fat tissue. One should not hesitate if the quality of the skin is uncertain to plan a second procedure from the start.
“ Eiderdown” effects are typical of micro-liposuctions carried out with needles on inappropriate surfaces.
Possible problems involving the reinjection area (receiver)
Results depend on fat survival, which is related to the quality of the fat collected, the implantation site (mobile or not), the patient’s health habits (body weight swings, cigarette smoking), the good healing conditions (heeding the postoperative prescriptions, avoidance of trauma…).
It is to be noted that secondary asymmetry or insufficiency of results may occur in case of irregular or insufficient fat collection, or simply because one preferred avoiding the risk of excessive correction and proceeding in two phases (such procedure, namely, has become standard for breast volume enhancement). A second lipostructure operation may be programmed if a collection site is available (presence of fat tissue stock in sufficient quantity and good skin quality). If the fat tissue stock proved inadequate or the skin is too damaged, for better results one should use a filling product or an implant.
In certain asymmetry cases, it is preferable to lower one’s ambitions and to equalize the results according to the side on which the procedure has been least successful. To this end, one should use suction, whenever possible (surface and body). When this is not possible (in certain localizations of the face that are too risky), surgical excision of the fat to be injected for treating the excessive corrections must be considered.
Thromboembolia accidents consecutive to liposuction
These are the most feared complications. Phlebitis may some times cause pulmonary embolus, the latter being lethal at times (1 case out of 10 000). This risk is increased by the long distance flights taking place too close to the operation date; by some diseases, and as has already been said, by surgery involving the pelvis such as plastic surgery of the abdomen. This is why the visit to anaesthetist and following the preventive measures are determinant: anti-thrombosis fastening, following possible anticoagulant prescriptions and early ambulation. In case of any doubt, it is possible nowadays, through DDimer assays (blood sample) to carry out screening tests.
Severe metabolic disturbances
These have been reported after liposuction procedures involving excessive quantities. The preoperative visit to the anaesthetist is determinant to avoid this type of situation.
Lymphatic exudates and necrosis
Such complications are quite exceptional when the operation is carried out properly, but it is to be noted that the risk for necrosis is enhanced in case of cigarette smoking.
At then beginning, oedema develops at the sites involved (postoperative swelling), which may give an even more swollen appearance at the donor sites than before the operation, and an overcorrected look at the injected sites.
In the injected areas, graft survival can be assessed after 6 months. In case of substantial liposuction, after 3 weeks / one month, the donor area is close to its initial appearance and the volume reduction becomes apparent only during the second month. One must wait 6 to 9 months to appreciate the final appearance as besides the fat cells that were aspirated during the procedure, damaged cells that were not aspirated will be evacuated progressively.
Two to three months following the operation, a first assessment of the result is possible. However, scars and tissues may at that time present peak inflammatory changes. Hence, one must often wait to evaluate the final outcome.
Mostly, a notable cosmetic effect is associated with a real psychological benefit.
After the healing phase, the durability of the results over time varies since the volume grafted follows the patient’s body weight variations according to the quality of the fat injected. This phenomenon is generally little noticeable as concerns localized corrections but may be more apparent in cases of important volume implants.
In the long run, it is to be noted that the fat cells that were grafted remain subject to the laws of cellular ageing (which, of course, is not interrupted by the operation). Thus, in the course of years, one may observe slow, natural, degradation of the grafted cells as well as that of the receiver site tissue wherein they were injected.
As regards liposuction of the collection sites, it is reminded that the durability of the results depends essentially on the patient’s health habits. The effect will be durable inasmuch as important body weight variations will be avoided.
To conclude, let us recall that precise, detailed information, in-depth analysis of the person’s motivations, patient-surgeon cooperation in the elaboration of the surgical program, surgical excellence as well as a good benefit-to-risk ratio analysis, heeding the pre- and postoperative recommendations, a regular follow up, are all necessary tools towards success in cosmetic surgery.
General information about fat transplants as well as the recommendation of the 12/26/2007 regarding fat injections in breasts (lipomodelling), are available on the page « lipostructure » of the SOFCPRE’s website (Société Française de Chirurgie Plastique Reconstructrice et Esthétique) : www.plasticiens.org
Doctor Sydney COLEMAN (USA) has developed the use of autologeous fat grafting (Coleman technique or Lipostructure) to rejuvenate the face (Coleman technique or Lipostructure):
COLEMAN SR. : Long-term survival of fat transplants: controlled demonstrations
Aesthetic Plast Surg. 1995 Sep-Oct;19(5):421-5
On the subject, the following publications and works can also be listed (this list obviously does not pretend exhaustiveness and may be amended):
1 – GUYURON B., MAJZOUB R.K. : Facial augmentation with core fat graft: a preliminary report
Plast Reconstr Surg. 2007 Jul ; 120(1):295-302
2 – COLEMAN S. R. : Facial augmentation with structural fat grafting
Clin Plast Surg. 2006 Oct ; 33(4):567-77
3 – COLEMAN S. R. : Structural fat grafting: more than a permanent filler
Plast Reconstr Surg. 2006 Sep;118(3 Suppl):108S-120S.
4 – FOYATIER J.L., MOJALLAL A., VOUILAUME D., COMPARIN J.P. : Évaluation de la restauration volumétrique par Lipostructure® en complément du lifting cervicofacial. À propos de 100 cas. – Clinical evaluation of structural fat tissue graft (Lipostructure) in volumetric facial restoration with face-lift. About 100 cases.
Ann Chir Plast Esthet. 2004 Oct;49(5):437-55
5 – MOJALLAL A., FOYATIER J.L. : Historique de l’utilisation du tissu adipeux comme produit de comblement en chirurgie plastique – Historical review of the use of adipose tissue transfer in plastic and reconstructive surgery
Ann Chir Plast Esthet. 2004 Oct ; 49(5):419-25
6 – TREPSAT F. : Periorbital rejuvenation combining fat grafting and blepharoplasties
Aesthetic Plast Surg. 2003 Jul-Aug ; 27(4):243-53
7 – COLEMAN S. R. : Hand rejuvenation with structural fat grafting
Plast Reconstr Surg. 2002 Dec ; 110(7) : 1731-44
8 – LITTLE J.W. : Applications of the classic dermal fat graft in primary and secondary facial rejuvenation
Plast Reconstr Surg. 2002 Feb ; 109(2):788-804
9 – TREPSAT F. : Volumetric face lifting
Plast. Reconstr. Surg. 2001 Oct ; 108(5):1358-70
10 – GUERREROSANTOS J. : Long-term outcome of autologous fat transplantation in aesthetic facial recontouring: sixteen years of experience with 1936 cases
Clin Plast Surg. 2000 Oct ; 27(4):515-43
11 – COLEMAN S. R. : Facial recontouring with lipostructure
Clin Plast Surg. 1997 Apr ; 24(2):347-67.
Specific information about fat transfers in mobile area of the face is based on Doctor Le Louarn’s practice, on his scientific works and on the following publications:
1 – LE LOUARN C, BUTHIAU D, BUIS J. : Structural aging: the Facial Recurve concept
Aesthetic Plast Surg. 2007 May-Jun;31(3):213-8.
2 – LE LOUARN C, BUTHIAU D, BUIS J. : The Face Recurve concept: medical and surgical applications
Aesthetic Plast Surg. 2007 May-Jun;31(3):219-31; discussion 232.
3 – LE LOUARN C, BUTHIAU D, BUIS J. : Rajeunissement facial et lifting malaire concentrique: le concept du FACE RECURVE® – Facial rejuvenation and concentric malar lift: the FACE RECURVE® concept
Ann Chir Plast Esthet. 2006 Apr;51(2):99-121.
4 – LE LOUARN C, BUTHIAU D, BUIS J. : Treatment of depressor anguli oris weakening with the face recurve concept
Aesthetic Surgery Journal, Volume 26, Issue 5, Pages 603-611C.
About lipomodelling (fat grafting used to increase breast volume), you may read :
1 – GOSSET J., FLAGEUL G., TOUSSON G., GUERIN N., TOURASSE C., DELAY E. : Lipomodelage et correction des séquelles du traitement conservateur du cancer du sein: Aspects médicolégaux. Le point de vue de l’expert à partir de cinq cas cliniques délicats – Lipomodelling for correction of breast conservative treatment sequelae. Medicolegal aspects. Expert opinion on five problematic clinical cases.
Ann. Chir. Plast. Esthet. 2007 Dec 2
2 – GOSSET J., GUERIN N., TOUSSON G., DELAPORTE T., DELAY E. : Aspects radiologiques des seins traités par lipomodelage après séquelles du traitement conservateur du cancer du sein – Radiological evaluation after lipomodelling for correction of breast conservative treatment sequelae
Ann. Chir. Plast. Esthet. 2007 Dec 3
3 – DELAY E., GROLLEAU J.L ., SITBON E . : Les implants mammaires en chirurgie esthétique et reconstructrice
50ème Congrès national de la SOF.CPRE (rapport annuel) sous la présidence du Dr G. FLAGEUL
Ann Chir Plast Esthet. 2005 Oct
4 – DELAY E., DELAPORTE T., SINNA. : Alternatives aux prothèses mammaires – Breast implant alternatives
Ann. Chir. Plast. Esthet. 2005 Oct Vol 50 N(6)