Application of Fat Grafting in Cosmetic Breast Surgery

Cool Fat, Hot Topic: A Systematic Review on Cryopreservation of Adipose Tissue

Autologous fat grafting is increasingly used in plastic, reconstructive, and esthetic surgery. Cryopreservation offers a promising solution for the long-term storage of adipose tissue, enabling multiple grafting sessions while minimizing patient discomfort associated with repeated liposuction for fat harvesting. This systematic review aims to analyze the current literature focusing on factors that influence the outcome of cryopreservation, including the use of cryoprotectants, the cooling and warming rate, the storage temperature, and the enrichment of cryopreserved fat grafts. A systematic search of the PubMed/MEDLINE database up to November 2024 was performed, including original preclinical and clinical studies written in English describing the cryopreservation of unprocessed or mechanically processed adipose tissue (macrofat, microfat, or nanofat). Eligible articles needed to describe the applied cryopreservation protocol, at least the storage temperature. Studies on cryopreservation of adipose-derived stem cells (ASCs), stromal vascular fraction, microvascular fragments, and other isolated components of adipose tissue were excluded. Data on cryoprotectants, cooling and warming rates, storage temperature, and eventual supplementation or enrichment of frozen fat were collected. Of the 679 records identified, 59 met the inclusion criteria. Adipose tissue cryopreservation at -80°C with a cryoprotectant, controlled slow cooling, and fast warming represented the most often applied protocol with encouraging outcomes in maintaining tissue survival and histological structure. Several studies indicated that the supplementation of frozen adipose tissue with ASCs improves tissue survival. Taken together, existing studies present diverse, and to some extent, conflicting results regarding cryopreservation protocols and their effects on adipose tissue viability. Hence, the ideal cryopreservation protocol for autologous fat remains to be established. Moreover, tailored protocols may be necessary for the cryopreservation of fat derivatives, such as nanofat.

Preconditioning Strategies for Improving the Outcome of Fat Grafting

Autologous fat grafting is a common procedure in plastic, reconstructive, and aesthetic surgery. However, it is frequently associated with an unpredictable resorption rate of the graft depending on the engraftment kinetics. This, in turn, is determined by the interaction of the grafted adipose tissue with the tissue at the recipient site. Accordingly, preconditioning strategies have been developed following the principle of exposing these tissues in the pretransplantation phase to stimuli inducing endogenous protective and regenerative cellular adaptations, such as the upregulation of stress-response genes or the release of cytokines and growth factors. As summarized in the present review, these stimuli include hypoxia, dietary restriction, local mechanical stress, heat, and exposure to fractional carbon dioxide laser. Preclinical studies show that they promote cell viability, adipogenesis, and angiogenesis, while reducing inflammation, fibrosis, and cyst formation, resulting in a higher survival rate and quality of fat grafts in different experimental settings. Hence, preconditioning represents a promising approach to improve the outcome of fat grafting in future clinical practice. For this purpose, it is necessary to establish standardized preconditioning protocols for specific clinical applications that are efficient, safe, and easy to implement into routine procedures.

Blockade of ITGA2/3/5 Promotes Adipogenic Differentiation of Human Adipose-derived Mesenchymal Stem Cells

The integrin α (ITGA) subfamily genes play a fundamental role in various cancers. However, the potential mechanism and application values of ITGA genes in adipogenic differentiation of human adipose-derived stem cells (hADSCs) remain elusive. This study confirmed that ITGA2/3/5 mRNA expressions were repressed during adipogenesis. Blockade of ITGA2/3/5 enhanced adipogenic differentiation of hADSCs. Oil red O staining found that more lipid droplets were apparent in the ITGA2/3/5 inhibition group following 14 d adipogenic induction than in the control group. In addition, inhibition of ITGA2/3/5 promoted the expression of adipogenesis-related genes (PPAR-γ, C/EBPα, FABP4). Mechanistically, ITGA2/3/5 functioned by regulating the Rac1 signaling pathway, which reasonably explains ITGA2/3/5's role in adipogenic differentiation of hADSCs. Our studies suggest that blockades of ITGA2/3/5 promote the adipogenic differentiation of hADSCs.

Fat Grafting Versus Implants: Who's Happier? A Systematic Review and Meta-analysis

Background: Breast implants were first introduced in the 1960s and have long been used for augmentation and reconstructive breast surgery. More recently, fat grafting for breast augmentation has gained popularity due to the 'natural' outcome and lack of implant-related complications. The aim of this study was to conduct a systematic review and meta-analysis comparing patient-related outcome measures between fat grafting and implant-based primary augmentation using the validated BREAST-Q questionnaire. Methods: A systematic review of the literature according to the PRISMA guidelines was conducted in PubMed®, Cochrane Library®, EMBASE®, MEDLINE®, and Scopus® databases. Papers were screened by two independent blinded reviewers. Quality was assessed using MINORS criteria. Results: Fourteen studies were included in the meta-analysis representing a total of 81 fat grafting augmentations and 1535 implant augmentations. The average overall patient satisfaction mean post-operative scores were 13.0 points higher in the implant group based on meta-regression (95% CI: 2.4-23.5; P = .016). There was no statistical difference in reported post-operative sexual well-being, psychosocial well-being, or physical well-being BREAST-Q scores. Conclusion: Although implant-based augmentation resulted in higher post-operative overall satisfaction scores, fat grafting remains a highly desirable alternative for augmentation in the right patient. This meta-analysis strongly highlights that careful patient selection and evaluation of patient goals must be assessed when selecting an augmentation method.

Are We Speaking the Same Language? A Systematic Review on the Use of Consistent Language in Reporting Fat Necrosis in Autologous Fat Grafting of the Breast

BACKGROUND

Autologous fat grafting is a widely adopted approach to optimize outcomes in breast reconstruction and augmentation. Although fat necrosis is a well-known consequence of autologous fat grafting, it remains inconsistently defined in the literature. In late 2014, the Food and Drug Administration released a draft guidance to restrict future autologous fat grafting-a statement that was permissively modified in late 2017. In the context of evolving guidelines and autologous fat grafting outcome data, the language and descriptions of fat necrosis are inconsistent in the literature.

METHODS

Five databases were queried for studies reporting fat necrosis following autologous fat grafting for breast reconstruction or augmentation from inception to August 11, 2022. Studies were temporally stratified according to released FDA guidelines: pre-2015, 2015-2017, and 2018-2022.

RESULTS

Sixty-one articles met inclusion criteria. Prior to 2015, 6 of 21 studies (28.6%) offered clear definitions of fat necrosis. In contrast, the 2015-2017 period demonstrated an absence of clear fat necrosis definitions (0/13 studies, p = 0.03). Though the 2018-2022 period exhibited a rise in annual publications compared with the pre-2015 period (5.4 vs. 1.9, respectively, p = 0.04), this was not matched by a rise in clear fat necrosis reporting (14.8% studies, p = 0.45). Across all periods, only 16.4% of articles offered clear definitions, which exhibited wide heterogeneity.

CONCLUSION

Despite the increasing popularity of autologous fat grafting, fat necrosis remains inconsistently defined and described, especially in the context of changing FDA guidelines. This limits the reliable interpretation and application of the current literature reporting fat necrosis outcomes.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Fatter Is Better: Boosting the Vascularization of Adipose Tissue Grafts

Adipose tissue resorption after fat grafting is a major drawback in plastic and reconstructive surgery, which is primarily caused by the insufficient blood perfusion of the grafts in the initial phase after transplantation. To overcome this problem, several promising strategies to boost the vascularization and, thus, increase survival rates of fat grafts have been developed in preclinical studies in recent years. These include the angiogenic stimulation of the grafts by growth factors and botulinum neurotoxin A, biologically active gels, and cellular enrichment, as well as the physical and pharmacological stimulation of the transplantation site. To transfer these approaches into future clinical practice, it will be necessary to establish standardized procedures for their safe application in humans. If this succeeds, the surgical outcomes of fat grafting may be markedly improved, resulting in a significant reduction of the physical and psychological stress for the patients.

Human adipose-derived mesenchymal stem cells-derived exosomes encapsulated in pluronic F127 hydrogel promote wound healing and regeneration

Background

Large area skin trauma has always been a great challenge for both patients and clinicians. Exosomes originating from human adipose-derived mesenchymal stem cells (hADSCs) have been a novel promising cell-free treatment in cutaneous damage repair. Nevertheless, the low retention rate of exosomes post-transplantation in vivo remains a significant challenge in clinical applications. Herein, we purposed to explore the potential clinical application roles of hADSCs-Exos encapsulated in functional PF-127 hydrogel in wound healing.

Methods

hADSCs-Exos were isolated from human hADSCs by ultracentrifugation. An injectable, biocompatible, and thermo-sensitive hydrogel Pluronic F-127 hydrogel was employed to encapsulate allogeneic hADSCs-Exos, and this complex was topically applied to a full-thickness cutaneous wound in mice. On different days post-transplantation, the mice were sacrificed, and the skin tissue was excised for histological and immunohistochemical analysis.

Results

Compared with hADSCs-Exos or PF-127 only, PF-127/hADSCs-Exos complexes enhanced skin wound healing, promoted re-epithelialization, increased expression of Ki67, α-SMA, and CD31, facilitated collagen synthesis (Collagen I, Collagen III), up-regulated expression of skin barrier proteins (KRT1, AQP3), and reduced inflammation (IL-6, TNF-α, CD68, CD206). By using PF-127/hADSCs-Exos complexes, hADSCs-Exos can be administrated at lower doses frequency while maintaining the same therapeutic effects.

Conclusion

Administration of hADSCs-Exos in PF-127 improves the efficiency of exosome delivery, maintains the bioactivity of hADSCs-Exos, and optimizes the performance of hADSCs-Exos. Thus, this biomaterial-based exosome will be a promising treatment approach for the cutaneous rejuvenation of skin wounds.

The protective role of FTY720 in promoting survival of allograft fat in mice

Fat transplantation is widely used for soft-tissue filling and wound repair. Owing to the biological changes in adipocytes in some metabolic diseases, allograft fat can provide a better source of donor fat than autologous fat. Fingolimod (FTY720) possesses a powerful immunomodulatory function. This study aimed to investigate the protective effect of FTY720 in allogeneic fat transplantation. C57BL/6J mice that received allografts were randomly divided into two groups and treated with saline and FTY720, respectively. Fat graft samples were obtained at 1, 6, and 20 weeks posttransplantation. Graft volumes, graft structure, and immune cells were estimated using histological examination, immunohistochemistry, staining immunofluorescence (IF), and quantitative real-time polymerase chain reaction (qRT-PCR). Inflammatory cytokine mRNA expression in grafts was detected by qRT-PCR. FTY720 treatment significantly enhanced allograft retention, structural integrity, and neovascularization, thereby demonstrating the potential of FTY720 in improving graft survival. Further IF staining showed that FTY720 increased regulatory T cell infiltration and reduced macrophage infiltration to some extent. FTY720 treatment also enhanced the expression of the anti-inflammatory cytokines interleukin (IL)-4 and IL-10 and weakened the expression of the pro-inflammatory cytokines TNF-α and IL-6. Furthermore, FTY720 treatment upregulated the expression of CD31 positive cells. This study demonstrated the potential efficacy of FTY720 in improving the graft survival rate of syngeneic fat allograft models, possibly by suppressing immune rejection and promoting angiogenesis. Therefore, this study offers key insights into the potential application of a drug-assisted strategy to prolong allograft fat survival.

Preoperative Risk Factors and Complication Rates of Breast Augmentation With Fat Grafting

BACKGROUND

The current literature on the complications and risk factors of autologous fat grafting (AFG) for breast augmentation is scant and inconclusive.

OBJECTIVES

The aim of this study was to use a large, multicenter database to determine the major complications and risk factors of patients undergoing breast augmentation with AFG in comparison to breast augmentation with implants.

METHODS

Patients undergoing breast augmentation with AFG as well as with implants between January 2, 2017 and July 31, 2019 were identified from the CosmetAssure database (Birmingham, AL). The primary outcome was the occurrence of major complication(s) requiring emergency department visit, hospital admission, or reoperation within 45 days postoperatively. Age, gender, BMI, smoking, diabetes, facility, ASA class, and anesthetic type were evaluated as risk factors.

RESULTS

Among the 76,128 patients enrolled in CosmetAssure, 789 (1.0%) underwent breast augmentation with AFG, in comparison to 18,544 (24.3%) patients with implants. The incidence of any major complication in the AFG cohort and implant cohort was 3.2% and 2.3%, respectively. Infection was significantly higher in the AFG cohort (1.1% vs 0.5%). Tobacco users were more likely to have any complication, infection, and pulmonary dysfunction/hypoxia on univariate analysis. ASA Class III/IV was more likely to have any complication and infection. On multivariate analysis, smoking was an independent risk factor for any complication (relative risk = 17.1) and infection (relative risk = 20.2).

CONCLUSIONS

Infection and hematoma are the most common major complications in breast augmentation with AFG. Tobacco use is the only independent risk factor for overall complications and infection. Breast augmentation with AFG has a higher infection rate than augmentation with implants.

LEVEL OF EVIDENCE: 4

Oil Cyst Formation after Lower Blepharoplasty with Fat Grafts

BACKGROUND

Fat grafting is increasingly used as an adjuvant surgery to blepharoplasty to refill the volume loss of an aged face and promote cellular regeneration. Complications, such as hematoma, infection, seroma, and palpable mass, may occur. We collected the patients that underwent lower blepharoplasty combined with fat graft to evaluate the incidence of oil cyst formation in the lower eyelid and to identify risk factors.

MATERIAL AND METHODS

A retrospective review was performed of all patients who underwent lower or total blepharoplasty combined with fat graft at the authors' institution between January 2018 and June 2020. Complication rates were observed, and associations between preoperative variables and outcomes were assessed.

RESULTS

A total of 119 patients were included in the series (all bilateral, 238 eyelids). The average patient age was 54.88 ± 11.94 years, and the average grafted fat was 1.88 ± 1.0 mL. On a per-eyelid basis for all patients, the complication rate of oil cyst formation was 6.72% (16 of 238 eyelids). The occurrence of oil cyst formation was associated with hypertension (P = 0.012; adjusted odds ratio, 9.27; 95% confidence interval, 1.62-52.99) and diabetes mellitus (P = 0.005; adjusted odds ratio, 14.02; 95% confidence interval, 2.22-88.45), but not associated with anticoagulants use (P = 0.931), age (P = 0.784), sex (P = 0.317), or fat volume (P = 0.215). The mean interval between the fat graft procedure and oil cyst noted was 236.5 ± 118.9 days.

CONCLUSIONS

Oil cyst in lower eyelid can be defined as a palpable, firm, and persistent subcutaneous cystic lesion found postoperatively in any size during physical examination. The complication rate of oil cyst formation occurring after lower blepharoplasty with autologous fat grafting is 6.72%. Hypertension and diabetes mellitus maybe are risk factors of oil cyst formation. Steroid injection, needle capsulotomy, liposuction, and excision are safe and effective treatments. Reduce surgical trauma by diminishing anterior lamina trauma and capsulopalpebral fascia repair might decrease the complication rate of oil cyst formation.Transconjunctival lower blepharoplasty with fat graft or 2-stage surgery may be a choice to prevent oil cyst formation.

Investigation of Autologous Fat Transfer in Capsule Formation around Silicone Implants in a Rat Model

BACKGROUND

In this experimental study, the authors investigated whether fat placement in the pocket during implant insertion affects capsule formation.

METHODS

Twenty albino Wistar rats, 400 g each, were used. The rats were divided into two groups, A and B, of 10 rats each. At the dorsum of each rat, four pockets (2 × 2 cm each) were dissected, two left and two right of the midline. In each pocket, a 1 × 1 × 1.5-cm silicone implant was inserted. In the two left pockets, only silicone implants were placed (control). In the two right pockets, 0.4 ml of fat was injected around the implant. Animals in group A were killed 2 months postoperatively, and those in group B were killed 4 months postoperatively. The implants were dissected with the capsule and sent for histopathologic examination.

RESULTS

The data of the fat transfer group was compared with control in groups A and B. Capsule thickness, neovascularization, myofibroblast layer thickness, and mast cell population demonstrated no statistically significant difference in either group A (p = 0.385, p = 0.862, p = 0.874, and p = 0.210, respectively) or group B (p = 0.338, p = 1.000, p = 0.288, and p = 0.344, respectively). Inflammation was statistically significantly less (p = 0.07) at 4 months (group B) in the fat transfer group compared to the control group. Likewise, cellularity was statistically significantly less (p = 0.019) at 4 months for the fat transfer group compared with the control group.

CONCLUSION

Fat injection in the pocket during implant placement may reduce inflammation and cellularity of capsules and predispose to faster capsule maturation.

CLINICAL RELEVANCE STATEMENT

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Cosmetic Breast Augmentation Using Power-Assisted Liposuction and Lipofilling: A Prospective Study

INTRODUCTION

Autologous fat transfer is becoming a more and more widespread procedure in aesthetic breast surgery. Power-assisted technology produces oscillating reciprocal movements of cannula tip, which reproduce the motion of the operator's arm with lower amplitude. The power-assisted mechanism can be applied to the fat liposuction and injection phases. The aim of this study is to report our experience on autologous fat transfer in primary cosmetic breast augmentation using power-assisted liposuction and lipofilling (PALL), our surgical technique and on long-term cosmetic results, and patient-reported outcomes.

MATERIALS AND METHODS

A prospective observational study was performed including all patients who underwent PALL cosmetic breast augmentation. Collected data included patient's age, BMI, mean liposuction and fat injection volume, mean operating time, postoperative complications, mean number of grafting procedures required to achieve the desired outcome, cosmetic results and patient satisfaction.

RESULTS

A total of 43 patients were included with a mean follow-up of 13.32 months. Mean liposuction and injection volumes were 1884.54 mL and 399.03 mL, respectively. Mean number of grafting procedures was 1.27. With respect to aesthetic outcomes, the mean score for breast volume, shape, symmetry and donor site shape was 4.38, 4.22, 4.27 and 4.42, respectively. Regarding patient satisfaction, the mean score for breast volume, shape, symmetry and donor site shape was 4.22, 5, 5 and 4.77, respectively.

CONCLUSION

The current study is the first prospective report on primary cosmetic breast augmentation using PALL. Although our sample of patients is limited, our results showed that PALL primary breast augmentation is an efficient procedure, which leads to satisfactory results for both patients and surgeons.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Mesenchymal stem/stromal cell therapy in atopic dermatitis and chronic urticaria: immunological and clinical viewpoints

Allergic diseases are immune-mediated diseases. Allergies share a common immunopathogenesis, with specific differences according to the specific disease. Mesenchymal stem/stromal cells (MSCs) have been applied to people suffering from allergic and many other diseases. In this review, the immunologic roles of MSCs are systemically reviewed according to disease immunopathogenesis from a clinical viewpoint. MSCs seem to be a promising therapeutic modality not only as symptomatic treatments but also as causative and even preventive treatments for allergic diseases, including atopic dermatitis and chronic urticaria.

Deciphering the Emerging Roles of Adipocytes and Adipose-Derived Stem Cells in Fat Transplantation

Autologous fat transplantation is widely regarded as an increasingly popular method for augmentation or reshaping applications in soft tissue defects. Although the fat transplantation is of simple applicability, low donor site morbidity and excellent biocompatibility, the clinical unpredictability and high resorption rates of the fat grafts remain an inevitable problem. In the sites of fat transplantation, the most essential components are the adipocyte and adipose-derived stem cells (ADSCs). The survival of adipocytes is the direct factor determining fat retention. The efficacy of fat transplantation is reduced by fat absorption and fibrosis due to the inadequate blood flow, adipocyte apoptosis and fat necrosis. ADSCs, a heterogeneous mixture of cells in adipose tissue, are closely related to tissue survival. ADSCs exhibit the ability of multilineage differentiation and remarkable paracrine activity, which is crucial for graft survival. This article will review the recent existing research on the mechanisms of adipocytes and ADSCs in fat transplantation, especially including adipocyte apoptosis, mature adipocyte dedifferentiation, adipocyte browning, ADSCs adipogenic differentiation and ADSCs angiogenesis. The in-depth understanding of the survival mechanism will be extremely valuable for achieving the desired filling effects.

FTY720 Improves the Survival of Autologous Fat Grafting by Modulating Macrophages Toward M2 Polarization Via STAT3 Pathway

Autologous fat grafting (AFG) is widely regarded as an important method for breast reconstruction after mastectomy among breast cancer (BC) patients. FTY720 has been proved to affect macrophage polarization and improve the sensitivity of postoperative BC treatment. This study aimed to explore FTY720 function and underlying mechanism in fat transplantation. The C57BL/6 J mice that received AFG were randomly divided into two groups treated with saline and FTY720, respectively. The fat graft samples were obtained at week 1, 2, 4, and 12 post-transplantation. Graft volumes, graft structures, M2 macrophages, and STAT3 protein expression were estimated by histological examination, immunofluorescence, flow cytometry, and western blot, respectively. In vitro, mouse preadipocytes were stimulated with FTY720 treated-M2 macrophages conditioned medium (FTY720-M2-CM) to evaluate the adipogenesis effect. The level of adipogenic mRNA expression in preadipocytes was detected by RT-PCR. The in vivo results showed that FTY720 treatment significantly enhanced the fat graft retention, structure integrity, and neovascularization, indicating the potential of FTY720 in improving graft survival. The histology results showed more polarized M2 macrophage presented in the FTY720 group. In the in vitro assay, after FTY720-M2-CM treatment, the 3T3-L1 preadipocytes showed the increased triglyceride content and adipogenic mRNA expression, including FABP4, C/EBP-α, Adipoq, and PPARγ. Furthermore, FTY720 treatment up-regulated the expression level of M2 biomarker CD206, Arg-1, Fizz-1, which could be weakened by the STAT3 inhibitor. Together, this study confirmed the potential efficacy of FTY720 in improving graft survival in the AFG model, possibly mediated by polarizing macrophages to M2 type through activating the STAT3 pathway.

Systematic Review: Allogenic Use of Stromal Vascular Fraction (SVF) and Decellularized Extracellular Matrices (ECM) as Advanced Therapy Medicinal Products (ATMP) in Tissue Regeneration

Stromal vascular fraction (SVF) containing adipose stem cells (ASCs) has been used for many years in regenerative plastic surgery for autologous applications, without any focus on their potential allogenic role. Allogenic SVF transplants could be based on the possibility to use decellularized extracellular matrix (ECM) as a scaffold from a donor then re-cellularized by ASCs of the recipient, in order to develop the advanced therapy medicinal products (ATMP) in fully personalized clinical approaches. A systematic review of this field has been realized in accordance with the Preferred Reporting for Items for Systematic Reviews and Meta-Analyses-Protocols (PRISMA-P) guidelines. Multistep research of the PubMed, Embase, MEDLINE, Pre-MEDLINE, PsycINFO, CINAHL, Clinicaltrials.gov, Scopus database, and Cochrane databases has been conducted to identify articles and investigations on human allogenic ASCs transplant for clinical use. Of the 341 articles identified, 313 were initially assessed for eligibility on the basis of the abstract. Of these, only 29 met all the predetermined criteria for inclusion according to the PICOS (patients, intervention, comparator, outcomes, and study design) approach, and 19 have been included in quantitative synthesis (meta-analysis). Ninety-one percent of the studies previously screened (284 papers) were focused on the in vitro results and pre-clinical experiments. The allogenic use regarded the treatment of perianal fistulas, diabetic foot ulcers, knee osteoarthritis, acute respiratory distress syndrome, refractory rheumatoid arthritis, pediatrics disease, fecal incontinence, ischemic heart disease, autoimmune encephalomyelitis, lateral epicondylitis, and soft tissue defects. The information analyzed suggested the safety and efficacy of allogenic ASCs and ECM transplants without major side effects.

[Cosmetic Breast Augmentation without Silicone Implants]

Cosmetic Breast Augmentation without Silicone Implants Abstract. Cosmetic breast augmentation procedures without silicone implants are becoming increasingly popular. Mastopexy can be adapted to the needs of the patient and usually result in an at least optical augmentation. Lipofilling is a safe procedure in reconstructive and aesthetic breast surgery and can help to restore natural appearance, compensate volume deficiencies, and correct asymmetries, that may be congenital or a consequence of prior surgeries. Cosmetic breast augmentation of very small breasts or when aiming at higher breast volumes using lipofilling only are usually combined with procedures for tissue expansion in order to increase the take rate of the injected fat. Hyaluronic acid injections is no valid alternative and are not recommended for cosmetic breast augmentation.