4

1. REVIEW ARTICLE
Autologous Fat Transfer for Breast Augmentation:
A Review
Mohammed A. Al Sufyani, MD,* Abdullah H. Al Hargan, MD,* Nayf A. Al Shammari,†
and Mohannad A. Al Sufyani†
BACKGROUND The use of autologous fat transfer for breast augmentation is still controversial due to ongoing
concerns regarding its efficacy and safety, most notably, concerns about breast cancer risk and detection.
OBJECTIVE To summarize the current knowledge on the safety and efficacy of autologous fat transfer for
breast augmentation with focus on clinical techniques, outcome, and complications.
METHODS A thorough search of the literature was conducted using the terms autologous fat transfer,
autologous fat grafting, and breast augmentation in the Medline and Embase databases, and relevant English
and German language articles were included.
RESULTS Findings were categorized in a step-by-step approach to the fat grafting procedure divided into
technique (harvesting, processing, and injection), postoperative care, graft viability enhancement, outcome,
complications, and breast cancer risk.
CONCLUSION Autologous fat transfer for breast augmentation is not yet standardized. Therefore, outcomes
vary widely depending on the surgeon’s expertise. The majority of reported complications are of low
morbidity, and based on available data, the procedure has a good long-term safety profile. Although there is
no evidence that fat grafting increases breast malignancy risk, long-term follow-up is required.
The authors have indicated no significant interest with commercial supporters.
In 1893, Neuber1
performed the first autologous fat
transplantation to fill depressed scars on the face.
Breast augmentation using autologous fat grafting was
first reported in 1895 by Czerny,2
transplanting an
excised lipoma from the back to restore the mound lost
by mastectomy. It was not until 1987, that Bircoll3,4
first
used a liposuction technique for autologous fat grafting
to the breast for augmentation. Unlike elsewhere in the
body, the breast tissuehas poorlyvascularized andloose
space that may impose havoc on implanted adipocytes
for breast augmentation and/or reconstruction, leading
to higher rates of complications and unsatisfactory
aesthetic outcomes.5
In 1987, the American Society of
Plastic Surgeons (ASPS) Ad Hoc Committee on New
Procedures condemned fat grafting to the breast due to
concerns that potential scarring and calcifications may
interfere with detection of breast cancer.6
In 2009, as
more data became available, the ASPS adopted a more
relaxed position, with the Fat Graft Task Force recently
stating that fat grafting may be considered for breast
augmentation, although they did not recommend it.
They found that, although fat grafting to the breast can
potentially interfere with the detection of breast cancer,
there is no strong evidence suggesting this interference.7
The breast indications included by the task force for fat
grafting are shown in Table 1.
In a 2010 survey of the ASPS conducted by
Gurunluogh and colleagues,8
73% of plastic surgeons
used fat grafting for breast reconstruction purposes,
*Department of Dermatology, Prince Sultan Military Medical City, Riyadh, Saudi Arabia; †
College of Medicine, King
Saud bin Abdulaziz University, Riyadh, Saudi Arabia
© 2016 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 1076-0512 ·Dermatol Surg 2016;42:1235–1242 ·DOI: 10.1097/DSS.0000000000000791
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© 2016 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.

2. and practice volume was correlated with the practice
of fat grafting. The majority of plastic surgeons per-
forming high-volume breast reconstruction reported
using fat grafting procedures routinely in breast
reconstruction.8
Because of its more natural outcome,
breast augmentation with autologous fat transfer has
become a successful alternative to implants. Com-
pared with implants, fat grafting has advantages and
disadvantages. Breast augmentation with fat is not
associated with implant-related complications such as
leakage, deflation, visible/palpable implants, or cap-
sular contracture. However, one major limitation to
fat grafting in breast augmentation is that the large
volume changes accomplished by implants cannot be
attained. One session of fat grafting results in a maxi-
mum size change of approximately one cup size,
without using any enhancement techniques. That said,
it is a safe and effective procedure.9,10
Methods
The authors searched the Medline (United States
National Library of Medicine, Bethesda, MD; using
the PubMed search engine) and Embase databases
(Elsevier Science, Amsterdam, Holland, the Nether-
lands; using the Embase search engine) using the
search terms autologous fat transfer, autologous fat
graft, and breast augmentation. The search was lim-
ited to English and German language articles indexed
as studies, clinical trials, randomized controlled trials,
systematic reviews, case series, or case reports. Find-
ings were summarized step by step, with the entire fat
grafting procedure divided into technique (harvesting,
processing, and injection), postoperative care, graft
viability enhancement, outcome, and complication.
Technique
The methodbywhichfatisharvestedandprocessed,the
amount and volume of fat injected into an area, the
quality of harvested fat, and cannulas used for har-
vesting and injecting are all factors that can affect the
survivalof thefat tobegrafted.9,11–13
Theresultsarealso
dependent on the surgeon’s technique and expertise.14
Harvesting
Graft harvesting, processing, and injection may have
an effect on the degree of success of the fat grafting
procedure. A review by Rosing and colleagues14
con-
cluded that harvesting, processing, and injection
techniques have a greater impact on graft survival,
but that it was unclear whether manual or machine-
assisted liposuction was superior for harvesting the
fat. Manual aspiration for harvesting typically
employs a 10-mL syringe9,14,15
connected to a 2-hole
cannula9,14
of 3-mm diameter.7,16
If vacuum liposuc-
tion is selected, low-pressure suction power is gener-
ally recommended to minimize damage to
adipocytes.7,13,15,16
Interestingly, a study examining
the effect of negative pressure on human fat grafts
revealed no difference between high- and low-suction
pressure.17
The choice of donor site for harvesting
fat grafts is dependent on adequate tissue volume
and patient/physician preference. There is no strong
evidence showing superiority of one donor site over
others.7,18
Notably, utilization of fresh fat tissue has
been recommended, because the viability of stored
adipocytes was reported to drop significantly, result-
ing in decreased grafting success.7
However, frozen fat
can be used in autologous fat grafting by adopting
a controlled freezing method with the addition of
a cryoprotective agent to improve subsequent cell
viability.19,20
Processing
In 1964, Rodbell21
first described an in vitro isolation
technique for mature adipocytes (supernatant) and
progenitor cells (infranatant) from rat tissue. Sub-
sequently, this method has been modified to increase
TABLE 1. Indications for Breast Augmentation
With Autologous Fat Graft
Micromastia
Post augmentation deformity, with and without implant
removal
Post lumpectomy deformity
Tuberous breasts
Deficits caused by conservative treatment or
reconstruction with implants and/or flaps (latissimus
dorsi or transverse rectus abdominis muscle)
Post mastectomy deformity
Poland syndrome
Nipple reconstruction and damaged tissue resulting
from radiotherapy
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3. the concentration of adipocytes for transplantation
and the overall fraction of adult stem cells.14
During
the processing phase, extreme care must be taken to
avoid contamination.16
Air exposure and mechanical
damage should be minimized, because they can poten-
tially damage adipocytes and decrease their sur-
vival.7,15,22
Processing fat grafts through centrifugation
in preparation for injection has been advised.7,9,14,17,22
Centrifuging the fat grafts at 3,000 rpm for 3 minutes
while still in the harvest syringe is generally recom-
mended.7
Exceeding 3,000 rpm may result in a higher
degree of adipocyte death.22
Centrifugation of fat grafts
is advantageous in that it separates the fat from mate-
rials that might increase adipocyte degradation (e.g.,
blood proteases, lipids, and lipases).7,14
However, other
studies have suggested that centrifugation has no
advantages for enhancing fat graft viability.14
Injection
At the time of injection, harvested fat is transferred
to 3-, 5-, or 10-mL syringes (Table 2)9,12,14–16,22
con-
nected to a blunt cannula with an average diameter of
2 to 3 mm (Table 2) to help minimize the mechanical
damage and shear force on the fat grafts, and optimize
viability.7,12,14–17,22
The authors believe that the
method by which the surgeon approaches the breast
for fat transfer, is dependent on his/her comfort and
experience. Some advocate dividing the breast into 4
quadrants and systematically augmenting each sub-
unit to avoid undercorrecting or overcorrecting these
units (Table 2).12
Placement of the incision site is also
case-dependent, and selected according to the sur-
geon’s goals and experience. Zheng and colleagues16
suggested that the inner half of the breast should be
accessed by placing the incision periareolarly, whereas
the lateral half would be best accessed through an
incision at the inframammary area. It is recommended
that fat be inserted into the breast in multiple layers
and tunnels, placing small aliquots along the way
while withdrawing the cannula, adding 1 to 3 mL at
each pass. This technique increases the contact
between the grafted fat and surrounding tissue,
allowing for better diffusion of nutrients and oxygen,
and improving survival during the time neededfor new
vessel formation.5,7,9,11,12,14,22,26–28
Bolus injection
should be avoided because of possible inadequate
delivery of essential nutrients and oxygen to adipo-
cytes located in the center of these large clumps of fat,
leading to fat necrosis resulting in the formation of
liponecrotic cysts and calcifications in the
breast.9,12,14,15
Different opinions exist on the planes in which fat
should be placed. Many authors recommend the
placement of grafted fat in the subcutaneous tissue
subglandularly, into the pectoralis major muscle or the
retropectoral space, and that breast parenchyma
should be avoided.13,14,16,22
Others advocate place-
ment into the intraglandular fat,9
a well-vascularized
tissue, to improve grafted fat survival and help
increase the prominence,12
and recommend against
TABLE 2. Summary of Injection Techniques in Clinical Studies
Study
Auxiliary
Method Injection Site
No. of
Sessions
Volume Injected,
mL
Coleman and Saboiero9
None Pectoralis major muscle, prepectoral
space, and subcutaneous tissue
1–3 50–460
Illouz and Sterodimas12
None Subcutaneous and intraparenchymal
tissue
1–5 240
Zheng and colleagues16
None Subcutaneous and subglandular tissue 1–3 73–101
Delay and colleagues15
None No data 1 140
Del Vecchio and
colleagues23
BRAVA No data 1 220–550
Yoshimura and
colleagues24
CAL Subcutaneous, pectoralis major, and
subglandular
1 270
Khouri and colleagues25
BRAVA Pectoral muscle, sub-pectoral plane, and
subglandular tissue
1 90–600
BRAVA, breast expansion device; CAL, cell-assisted lipotransfer.
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4. grafted fat placement into the subglandular area,
because it may not be well vascularized.12
Placing the
grafted fat into the subcutaneous plane helps shape
the breast.9
Some experts stop after two-thirds of the
procedure, position the patient in a sitting posture for
a moment to evaluate the near-final results, and then
return the patient to supine position for completion.11
Del Vecchio22
presented an interesting technique
named “reverse liposuction” for transferring fat grafts
in the breast, whereby the fat grafts are placed in a 30
to 60 mL syringe connected to intravenous extension
tubing that is in turn connected to the injection can-
nula. The surgeon inserts the cannula into the breast
while the assistant simultaneously pushes down the
plunger of the syringe at a pace determined by the
surgeon, thus allowing the delivery of a larger amount
of fat graft in a shorter time.
Special cases deserve additional attention. During
breast augmentation with fat grafts in patients with
Poland syndrome, extreme caution is necessary in the
subclavian area, because subclavian vessels may be
lower than usual.15
Fat should not be injected under
the nipple–areolar complex when correcting the
deformity of a tuberous breast.9
In cases of tethered
scar tissue in the breast, multiple passes with the can-
nula may mesh the scar tissue, resulting in its expan-
sion and improvement.29
The volume of injected fat grafts for breast augmen-
tation, averages between 50 and 150 mL per breast in
1 session.12,14,26
Because of the resorption of some fat
that occurs in the postoperative period, slight over-
correction during the augmentation procedure is
generally advised. Some experts recommend 140%
correction.15,22
Mega-volume fat grafting has been
defined in the literature as transplanting over
300 mL.23
If a repeated session is desired, a period of
1 to 3 months between sessions is recommended.12,30
Postoperative Care
After the procedure, the patient is usually given anti-
biotics and analgesics as needed, and asked to limit
activity for the following 3 to 7 days. Cold com-
pressors may be used to help with the resulting edema,
which normally resolves in the following 4 weeks.11
This edema, when it completely resolves, may give the
impression to the patient that approximately 50% of
the breast volume has resorbed, so education is para-
mount. Bruising, when it occurs, usually resolves after
2 weeks.15
The patient is usually asked to wear a sur-
gical bra to support both breasts during the first 7
postoperative days.16
Enhancement of Fat Graft Viability
Adipose-derived regenerative cells (ADRC) are plen-
tiful and retain the potential to differentiate into var-
ious cell types, unlike stem cells harvested from adult
bone marrow or blood that are limited in number and
require cell culturing.11
Adipose-derived regenerative
cells can secrete growth factors that enhance neo-
angiogenesis, prevent apoptosis, and encourage adi-
pocyte differentiation, improving the long-term
retention and quality of grafted fat.11
Nonetheless,
ADRC could have a potential risk of malignant
transformation.14
Yoshimura and colleagues24
repor-
ted that cell-assisted lipotransfer improved the viabil-
ity of the transferred adipocyte for cosmetic breast
augmentation. An intriguing device, the BRAVA
(Brava, LLC, Miami, FL), a vacuum-based external
soft-tissue expander originally used as a nonsurgical
breast enlargement system, has been successfully
applied preoperatively to autologous fat grafting. The
device works by extending the skin, expanding the
underlying recipient space, and stimulating concomi-
tant angiogenesis, thus improving the survival rate and
allowing grafts of larger volume. This combination of
angiogenesis stimulation and skin stretching is
believed to be beneficial because of the increased vas-
cularity and volume of the recipient area.23,25,31–33
A
limitation of this device is that patients are required to
wear it for approximately 10 to 12 hours per day for 4
weeks before the procedure.34
Furthermore, the device
had little benefit when the patients had contracted
skin, such as after postradiation therapy,35
because the
pressure rises quickly in scarred tissue with only small
amounts of fat graft.36
Moreover, techniques and approaches to further
increase the viability of transplanted adipocytes for
breast augmentation have also been reported. Platelet-
rich plasma (PRP) mixed with fat grafting was
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5. reported to improve the maintenance of breast volume
and enhance skin quality resulting in a softer and
a more natural breast contour.27,37
By contrast, other
studies38
have shown higher incidence of liponecrosis
in patients treated with PRP compared with fat alone,
and no change in the number of sessions required for
the final result. In summary, the use of ADRC and/or
PRP combination in autologous fat grafting remains
controversial and has been called into question by
regulators.39–41
Clinical Outcome (Efficacy)
The clinical outcome of any surgical procedure is
important to both the patient and surgeon. Reaching
the desired outcome from breast augmentation
through autologous fat transfer likely requires 1 to 5
sessions (average of 3 sessions), which is a major dis-
advantage for the procedure and may discourage
patients from undergoing the surgery.12
Major factors
affecting the required number of sessions are sustain-
ability and uptake of the final volume of transplanted
adipocytes, which in turn depend on many variables.
One such variable is the patient’s weight, which must
be stable at the time of the procedure. If the patient
loses weight after undergoing surgery, the volume of
transferred fat will decrease. At the other end of the
spectrum, if the patient gains weight, breast volume
will increase, which seems to have a positive effect on
the resorption rate of the follow-up session.22
To
compensate for some of the secondary loss to resorp-
tion of transplanted fat grafts, some experts advocate
overcorrection.7
However, overcorrection must be
performed with care, not to increase the tissue tension,
which by itself may cause more local ischemia, hence
reducing the survival of transplanted adipocytes.30
This risk may be reduced when the skin of the treated
breast is thinner and easier to stretch.11
On average,
approximately 30% to 40% of the total fat transferred
is lost to resorption. This rate may be even higher
(40%–50%) if the harvested fat is very oily.22,42
Usu-
ally, the volume of the transplanted fat grafts stabilizes
by 4 to 8 months after the last session.9,30
This stable
volume may last 5 to 6 years.22
Notably, autologous
fat transfer does not provide a breast-lifting effect
for ptotic breasts and may actually accentuate
ptosis.43,44
Complications
Major complications of breast augmentation from
autologous fat grafting can be prevented through multi-
plesessions.12
Themajorityofthereportedcomplications
(60%) are of low morbidity and commonly reported
after breast surgery, such as breast mass or induration.5
Interestingly, the complication rate after autologous fat
transfer for breast augmentation was lower than those
occurring after other aesthetic breast implants or myo-
cutaneous flaps.5
The complication rate correlates highly
with the surgeon’s technique, when it is mentioned. In
general,earlycomplications(occurringwithin4weeksof
the procedure) may include infection of the surgical
(donor or grafted) site ranging from mild superficial
infection to severe abscess formation requiring incision
and drainage. Late complications after 4 weeks from the
procedure may include liponecrotic cyst formation,
grafted fat necrosis or resorption, calcification, and
unsatisfactory results. The incidence of radiographic and
infectious side effects is highest with bolus injection.7,14,45
Complications may also include ecchymosis, striae,
hematoma, and long-term breast asymmetry.12
Many of
these adverse effects may be easily avoided with multiple
sessionsovertimeusingsmallamountsofautologousfat.
Interestingly, complications from autologous fat transfer
tothebreastseemtobemorefrequentthanthosetoother
sites.46
To optimize the aesthetic outcome, the surgeon is
advised to place the site of entry wounds in the sub-
mammary folds, axillary tails, or areolar region.15
Although most reported complications are not life
threatening, it should be mentioned that a case of intra-
operativepneumothorax15
andacaseofsepsisassociated
with multiple abscesses47
have been reported.
Liponecrotic Cyst and Fat Necrosis
This complication is probably the most important
because it is the most frequent,7
with a reported inci-
dence ranging from 3% to 17%.11,16
Fat necrosis
occurs when the transplanted fat is injected in large
amounts.16,26
With this technique, only the peripheral
part of the injected fat has contact with the sur-
rounding tissue, whereas the central region does not.
Consequently, the central region undergoes necrosis
and liquefaction secondary to insufficient supply from
the surrounding tissue. In the event that necrotic fat
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6. tissue is not completely resorbed, it undergoes fibrosis
and calcification. In the early stages of this trans-
formation, when the center has not yet liquefied, it
presents as a hard, well-defined mass. In the following
stages, when the center has undergone liquefaction, it
becomes cystic. Once fibrosis, sclerosis, or calcifica-
tion occurs, autoresorption is not possible.26
This
complication typically presents 6 months to 6 years
after the initial procedure,46
but has been reported
even 10 years after the fat transfer session.48
Most
liponecrotic cysts are found in the subglandular layer
of the breasts,14
but they may also occur in the sub-
muscular and subcutaneous planes,47
and may occur
unilaterally or bilaterally.49
Sonography seems supe-
rior to mammograms in detecting and differentiating
a cystic lesion from a solid one after fat transfer for
breast augmentation.16
Even if distinguishable from
cancer on a sonogram, they are still likely to be biop-
sied to rule out the remote possibility of breast cancer
to relieve patient anxiety and avoid litigious sit-
uations.9,16
The best approach to managing these
complications is to decrease their risk of occurrence. It
is of paramount importance to fix the breast using
a surgical bra for the first 7 days after the fat transfer
session, to avoid the local aggregation of grafted fat
caused by movement of the pectoralis major muscle.16
In the majority of cases of liponecrotic cysts formation,
the lumps did not interfere with the final contour of the
breast.16
When intervention is required, approaches
described in the literature include needle aspiration,11,16
surgical extirpation,16
and ultrasound-assisted liposuc-
tion.50
Other modified techniques such as “needle aer-
ation” have also been reported as helpful.51
Regardless
of the chosen surgical approach, it is important to
be mindful of the possible risk of leakage of the oily
content of the cyst, which may incite a granulomatous
reaction.16
Nonetheless, these liponecrotic cysts are not
exclusive to autologous fat transfer for breast augmen-
tation,andmayoccurwithanytypeofbreastsurgery.9,46
Radiographic Impact
There has been great concern that breast augmentation
through autologous fat transfer will hinder breast imag-
ing in future follow-up visits and may obscure the dif-
ferentiation from mammary tumors. Findings of benign
radiological stigmata after a fat transfer session may
show a radiolucent round or oval mass with thin-walled
calcifications, or “eggshell.” A more typical finding of fat
necrosis is the formation of an oil cyst or coarse irregular
calcifications.14
These findings have been shown not to
affect the radiographic follow-up of patients after breast
augmentation by fat transfer.5,15,52
Even when using the
American College of Radiology classification or the
American College of Radiology Breast Imaging Report-
ing and Data System categorization before and after
grafting,theuniquefeaturesofthegraftedfat nodulesare
helpful in differentiating them from mammary masses.53
The risk of such radiographic changes after fat transfer is
similar to that after other breast surgical procedures.5
Furthermore, the radiological findings obtained on
mammograms after autologous fat transfer were
observed to improve 1 year after the procedure.5
Breast Cancer Risk
The fearof increasingtheriskof breast cancerstillexists
for some, who strongly advocate the complete aban-
donment of fat transfer for breast augmentation until
further studies are performed, despite the absence of
evidence.54
Nonetheless, according to the ASPS Fat
Graft Task Force, there is no literature suggesting an
increased risk of breast malignancy associated with fat
grafting.14
Adipocyte-derived mesenchymal stem cells
(ASC) and adipocyte-derived stem cells (ADSC) have
beensuggested,bylimiteddata,tobeapotentialriskfor
promoting the growth of subclinical breast cancer.55,56
Local production of estrogen by adipocyte-derived
aromataseisone postulatedmechanism forthiseffect.14
Interestingly, the same ASC were also shown to
decrease the expression of a specific protein that
potentiates the invasiveness of breast cancer, and an
animal study conversely showed inhibition of breast
cancer metastasis by ASC.57
Hypothetically, if these
transplanted ADSC have the potential to promote the
growth or metastasis of a new or recurrent breast
malignancy, the breast itself is not totally devoid of
adipocyte tissue, hence there is absolutely no shortage
of such cells from local resources from which it can
recruit.58
Even if an increase in growth factors after the
fat transfer procedure is considered a risk for breast
cancer, these factors would only be increased for the
first 2 weeks, even with stem cell enhancement.29
It
should be mentioned that, even if complications of the
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7. breast augmentation by fat transplantation, namely fat
necrosis and calcifications, have the potential to impede
breast cancer detection, then all types of breast surgery
should be similarly condemned, because these compli-
cations are consequences of all breast surgeries.46
Having evaluated the factors possibly impacting the risk
of breast malignancy after fat transfer on a cellular level,
the authors turn to clinical evidence for this phenome-
non in the literature. Some experimental studies have
reported that transplanted preadipocytes and mature
adipocytes may carry carcinogenic potential in the
breast.55,59
However, these claims were refuted in
a recent systemic review of experimental studies on the
same topic.5
Studies following patients who underwent
autologous fat transfer for breast augmentation after
lumpectomy or even mastectomy have not shown any
increase in the local recurrence of breast cancer even
after10years.14,60
Interestingly,onestudyexaminingthe
riskoflocalrecurrenceafterfattransplantationobserved
an even higher rate in controls who did not undergo the
procedure.5
The literature also indicates that post-
operative follow-up of patients with breast cancer who
underwent the fat transfer procedure was not hindered,
and imaging-guided biopsy was possible.7,12
It has been
suggested that transplanting the fat grafts into the sub-
cutaneous or subglandular regions carried a lower risk
for breast malignancy compared with transplantation
into the parenchyma.58
In summary, as with any type of
breast surgery, patients undergoing autologous fat
transfer should have a baseline mammogram, and
undergo mammogram screening on a regular basis, as
wellasbeeducatedinproperbreastself-examination.9,11
Conclusion
Autologous fat grafting may be considered for use in
breast augmentation; as for other sites, the specific
techniques of fat graft harvesting, processing, and
injection are not yet standardized. Therefore, the out-
comes vary dramatically depending on the surgeon’s
technique and experience. The majority of the reported
complications are of low morbidity, and based on
availabledata,theprocedurehasagoodlong-termsafety
profile. Although there is no evidence that fat grafting
increasestheriskofbreastmalignancy,long-termclinical
and radiological follow-up is recommended.
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Address correspondence and reprint requests to: Abdullah
H. Al Hargan, MD, Department of Dermatology, Prince
Sultan Military Medical City, PO Box 281681, Riyadh
11392, Saudi Arabia, or e-mail: aalhargan@psmmc.med.sa
A U T O L O G O U S F A T T R A N S F E R F O R B R E A S T A U G M E N T A T I O N
D E R M A T O L O G I C S U R G E R Y
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