Prognostic Significance and Management of Sentinel Nodes in the Triangular Intermuscular Space of Patients with Melanoma.

BACKGROUND: The clinical significance of sentinel nodes (SNs) in the triangular intermuscular space (TIS) of patients with melanoma is poorly understood. This study aimed to determine their incidence and positivity rate, and to report their management and patient outcomes. METHODS: This was a single-institution retrospective cohort study of patients with unilateral or bilateral TIS SNs on lymphoscintigraphy treated between 1992 and 2017. Recurrence-free survival was analyzed. RESULTS: Lymphoscintigraphy identified TIS SNs in 266 patients. They were bilateral in 17 patients. Of the 2296 patients with a melanoma on the upper back, 259 (11%) had TIS SNs. Procurement of SNs was not attempted in 122 (43%) of the 283 cases and failed in 11 cases (7%). An SN was successfully retrieved from the TIS in 145 patients (53%) and contained metastasis in 18 of 150 TIS SNs. This was the only positive SN in 12 patients (8%), upstaging all of them. Of the 18 patients with a positive SN in the TIS, 9 (50%) underwent completion axillary lymph node dissection, but no additional involved nodes were found in any of these patients. Recurrence in the TIS was observed in six patients (5%), none of whom had their TIS SN surgically pursued previously. CONCLUSIONS: Lymphoscintigraphy showed TIS SNs in 11% of patients with melanomas on their upper back. In such cases, retrieval of TIS SNs is required for accurate staging and to minimize the risk of TIS recurrence.

Efficacy of mesenchymal stem cell-delivery using perpendicular multi-needle injections to the skin: Evaluation of post-ejection cellular health and dermal delivery.

AIM: Mesenchymal stem cell (MSC)-therapy is increasingly being evaluated in clinical trials. Dermal delivery is not only time consuming but also unreliable, potentially hampering the therapeutic result. Therefore, qualification of cell delivery protocols is essential. This study evaluated a clinically relevant automated multi-needle injection method for cutaneous MSC-therapy, allowing the skin to be readily and timely treated, by assessing both the cellular health post-ejection and dermal delivery. METHODS: Following dispensation through the injector (31 G needles: 9- or 5-pin) the cellular health and potency (perceived- and long-term (12 h) viability, recovery, metabolism, adherence, proliferation and IDO1-expression) of adipose-derived stem cells (10-20-50 ×106 cells/ml) were assessed in vitro in addition to dermal delivery of solution in human skin. RESULTS: No significant detrimental effect on the perceived cell viability, recovery, metabolism, adherence or IDO1-expression of either cell concentration was observed. However, the overall long-term viability and proliferation decreased significantly regardless of cell concentration, nonetheless marginally. An injection depth above 1.0 mm resulted in all needles piercing the skin with dermal delivery from up to 89% needles and minimal reflux to the skin surface, and the results were confirmed by ultrasound and histology. CONCLUSION: The automated injector is capable of delivering dermal cell-doses with an acceptable cell quality.

Fat Grafting With Expanded Adipose-Derived Stromal Cells for Breast Augmentation: A Randomized Controlled Trial.

BACKGROUND: The main challenge with fat grafting is loss of some of the graft to postsurgery resorption. Previous studies suggest that adipose-derived stromal cells (ASCs) can improve the volume retention of fat grafts but there is a lack of randomized trials to support the use of ASCs in clinical practice. OBJECTIVES: This trial aimed to investigate whether ASCs improve fat graft volume retention in patients undergoing breast augmentation with lipofilling. METHODS: This was a double-blind, randomized controlled trial of breast augmentation with ASC-enriched fat grafting. Healthy women aged 30 to 45 years were enrolled. First, the participants underwent liposuction to obtain fat for culture expansion of ASCs. Then, the participants were randomly assigned to undergo a 300- to 350-mL breast augmentation with ASC-enriched fat grafting (10 × 106 ASCs/mL fat graft) to 1 of their breasts and placebo-enriched fat grafting of identical volume to the contralateral breast. The primary outcome was fat graft volume retention after a 1-year follow-up measured with MRI. The trial is registered at www.clinicaltrialsregister.eu (EudraCT-2014-000510-59). RESULTS: Ten participants were included in the trial; all completed the treatment and follow-up. No serious adverse events occurred. Fat graft volume retention after 1 year was 54.0% (95% CI, 30.4%-77.6%) in the breasts treated with ASC-enriched fat grafting (n = 10) and 55.9% (95% CI, 28.9%-82.9%) in the contralateral breasts treated with placebo-enriched fat grafting (n = 10) (P = 0.566). CONCLUSIONS: The findings of this trial do not support that ASC-enriched fat grafting is superior to standard fat grafting for breast augmentation.

Factors associated with melanoma-related limb lymphoedema.

BACKGROUND: Melanoma-related limb lymphoedema is a well-known late effect following sentinel node biopsy (SNB), and lymph node dissection (LND) in patients treated of melanoma. However, data on associated risk factors are sparse. This study aimed to investigate factors associated with melanoma-related limb lymphoedema. METHODS: The present cross-sectional single-center clinical study included patients between 18 and 75 years with American Joint Committee on Cancer Stages I-III melanoma treated with wide local excision (WLE) and unilateral axillary or inguinal SNB and/or completion LND (CLND) or therapeutic LND (TLND). The diagnosis of secondary unilateral limb lymphoedema was based on the history, symptoms, and physical examination and staged according to the International Society of Lymphology (ISL). Data on factors associated with lymphoedema were analysed with binary logistic regression models. RESULTS: In total, 642 patients were eligible, of which 435 (68%) patients participated in the study. Among these 431 patients, 109 (25%) had lymphoedema of which 48 (44%), and 61 (56%) were classified with ISL Stages I and II-III, respectively. Multivariate analyses identified primary tumour on the limb (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.17-4.56; p value .017), inguinal surgery (OR, 6.91; 95% CI, 3.49-14.11; p value <.0001), LND (OR, 6.45; 95% CI, 3.18-13.57; p value <.0001), and persistent pain at the site of lymph node surgery as factors associated with lymphoedema (OR, 3.52; 95% CI, 1.54-8.19; p value .003). Multivariable analysis of ISL Stage II-III lymphoedema further identified limb cellulitis to be associated with lymphoedema (OR 5.74; 95% CI, 2.11-15.99; p value .0006). CONCLUSIONS: Melanoma-related limb lymphoedema is associated with inguinal surgery, LND, primary tumour on the limb, persistent pain at the site of lymph node surgery, and cellulitis of the limb. This study highlights the importance of increasing awareness, improving prevention, and treatment of melanoma-related limb lymphoedema.

Mesenchymal stem cell therapy of acute thermal burns: A systematic review of the effect on inflammation and wound healing.

AIM: Mesenchymal stem cell (MSC) therapies are emerging as a promising strategy to promote tissue repair, and may extend their utility to burn care. This comprehensive review of the extant literature, evaluated all in vivo studies, to elucidate the potential protective and therapeutic effect of MSCs in acute thermal skin burns. METHODS: PubMed was systematically searched, according to PRISMA guidelines, and all relevant preclinical and clinical studies were included according to pre-specified eligibility criteria. RESULTS: Forty-two studies were included in a qualitative synthesis, of which three were human and 39 were animal studies. The preclinical studies showed that MSCs can significantly reduce inflammation, burn wound progression and accelerate healing rate of acute burns. The underlying mechanisms are complex and not fully understood but paracrine modulators, such as immunomodulatory, antioxidative and trophic factors, seem to play important roles. Allogeneic MSC therapy has proved feasible in humans, and could allow for prompt treatment of acute burns in a clinical setting. CONCLUSION: MSC therapy show positive results, regarding improved burn wound healing and immunologic response. However, most findings are based on small animal studies. Randomized clinical trials are warranted to investigate the regenerative effects in human burns before translating the findings into clinical practice.

New Validated Method for Measuring Fat Graft Retention in the Breast with MRI.

In this study, we present a new method for measuring fat graft volume retention in the breast based on magnetic resonance imaging scans and a validation study to assess its accuracy and precision. The method was validated by 4 observers using the magnetic resonance imaging scans of 14 patients undergoing breast augmentation with fat grafting. The method was translated into software and was used to measure the change in breast volume from a preoperative scan to a postoperative scan recorded within 3 hours after the surgery, which was compared with the injected fat graft volume. The new method measured the injected fat graft volumes with an average systematic overestimation of 6.3% (SD, 10.5). The median interobserver variation was <7%. We propose that this new method can be a good alternative to previous techniques for clinical research purposes. The software can be made available upon request free of charge for use on the MeVisLab platform.

Cell-Enriched Fat Grafting Improves Graft Retention in a Porcine Model: A Dose-Response Study of Adipose-Derived Stem Cells versus Stromal Vascular Fraction.

BACKGROUND: Cell-enrichment of fat grafts has produced encouraging results, but the optimal concentrations and types of added cells are unknown. The authors investigated the effects of enrichment with various concentrations of ex vivo-expanded adipose-derived stem/stromal cells and stromal vascular fraction on graft retention in a porcine model. METHODS: Adipose-derived stem/stromal cells were culture-expanded, and six fat grafts (30 ml) were prepared for each minipig (n = 13). The authors investigated grafts enriched with 2.5 × 10 to 20 × 10 adipose-derived stem cells/ml and stromal vascular fraction and nonenriched control grafts. Each pig served as its own control. Magnetic resonance imaging was performed immediately after grafting and 120 days postoperatively before the pigs were euthanized, and histologic samples were collected. RESULTS: The authors recorded an enhanced relative graft retention rate of 41 percent in a pool of all cell-enriched grafts compared to the nonenriched control (13.0 percent versus 9.2 percent; p = 0.0045). A comparison of all individual groups showed significantly higher graft retention in the 10 × 10-adipose-derived stem/stromal cells per milliliter group compared with the control group (p = 0.022). No significant differences were observed between the cell-enriched groups (p = 0.66). All fat grafts showed a significantly better resemblance to normal fat tissue in the periphery than in the center (p < 0.009), but no differences in overall graft morphology were observed between groups (p > 0.17). CONCLUSIONS: Cell-enriched fat grafting improved graft retention and was feasible in this porcine model. No significant differences in graft retention were observed among the various adipose-derived stem/stromal cell concentrations or between adipose-derived stem/stromal cell and stromal vascular fraction enrichment. Future studies using this model can help improve understanding of the role of adipose-derived stem/stromal cells in cell-enriched fat grafting.

The current gold standard breast volumetry technique seems to overestimate fat graft volume retention in the breast: A validation study.

BACKGROUND: MRI is generally considered as the gold standard for measuring breast volume because of its high accuracy of the modality. Many techniques used to measure total breast volume have been validated, but none of these techniques have been validated for their ability to measure the volume retention of fat grafts in the breast. In this study, the authors investigated the accuracy of the most common MRI technique used to measure fat graft retention in the breast by measuring the volume changes after breast augmentation. METHODS: Patients undergoing breast augmentation with either breast implants or fat grafting underwent MRI scans before and after surgery. Blinded observers measured the change in breast volume from the MRI scans. The difference between the measured change in breast volume and the volume of the breast augmentation was used to determine the accuracy of the MRI technique. RESULTS: Twenty-eight patients with a total of 56 breasts were included. In total, 168 measurements of change in breast volume were performed by the observers. The MRI measurements of change in breast volume overestimated the true volumes of the breast augmentations by an average of 50.8%, and only 8 of the 168 individual measurements had measurement errors below 50 mL. CONCLUSION: The MRI technique, which is considered as the gold standard for the quantification of fat graft volume retention, was associated with a significant measurement error. These findings have potential implications for the interpretation of previously published results of studies based on this technique.

Efficacy of breast reconstruction with fat grafting: A systematic review and meta-analysis.

BACKGROUND: Breast reconstruction with fat grafting is a new alternative to prosthetic implants and flaps for women with breast cancer. In this study, we investigate the efficacy of fat grafting for breast reconstruction in a meta-analysis. METHODS: The study followed the PRISMA and MOOSE guidelines for systematic reviews and meta-analyses. Studies were included if the patients underwent complete breast reconstruction with fat grafting as the only treatment modality. The number of fat grafting treatments needed to complete a breast reconstruction was modeled in a meta-analysis for five treatment categories: modified radical mastectomy, skin-sparing mastectomy, and breast-conserving surgery; the two mastectomy groups were subdivided into nonirradiated and irradiated. RESULTS: Twenty-one studies were included in the meta-analysis. The studies comprised 1011 breast reconstructions in 834 patients. The estimated numbers of treatments to complete a reconstruction were 2.84-4.66 in the mastectomy groups and 1.72 in the breast-conserving surgery group. The number of fat grafting sessions needed to complete a breast reconstruction was significantly higher for the irradiated patients than for the nonirradiated patients (p < 0.05). There was no significant difference in the number of fat grafting sessions needed to complete a breast reconstruction after a modified radical mastectomy versus a skin-sparing mastectomy. CONCLUSIONS: This study provides an evidence-based foundation for several practical issues related to breast reconstruction with fat grafting. The analysis showed that radiotherapy is the most important factor associated with the number of treatment sessions needed to complete a breast reconstruction and with the rate of complications.

A Novel Porcine Model for Future Studies of Cell-enriched Fat Grafting.

BACKGROUND: Cell-enriched fat grafting has shown promising results for improving graft survival, although many questions remain unanswered. A large animal model is crucial for bridging the gap between rodent studies and human trials. We present a step-by-step approach in using the Göttingen minipig as a model for future studies of cell-enriched large volume fat grafting. METHODS: Fat grafting was performed as bolus injections and structural fat grafting. Graft retention was assessed by magnetic resonance imaging after 120 days. The stromal vascular fraction (SVF) was isolated from excised fat and liposuctioned fat from different anatomical sites and analyzed. Porcine adipose-derived stem/stromal cells (ASCs) were cultured in different growth supplements, and population doubling time, maximum cell yield, expression of surface markers, and differentiation potential were investigated. RESULTS: Structural fat grafting in the breast and subcutaneous bolus grafting in the abdomen revealed average graft retention of 53.55% and 15.28%, respectively, which are similar to human reports. Liposuction yielded fewer SVF cells than fat excision, and abdominal fat had the most SVF cells/g fat with SVF yields similar to humans. Additionally, we demonstrated that porcine ASCs can be readily isolated and expanded in culture in allogeneic porcine platelet lysate and fetal bovine serum and that the use of 10% porcine platelet lysate or 20% fetal bovine serum resulted in population doubling time, maximum cell yield, surface marker profile, and trilineage differentiation that were comparable with humans. CONCLUSIONS: The Göttingen minipig is a feasible and cost-effective, large animal model for future translational studies of cell-enriched fat grafting.

Targeted ultrasound and fine-needle aspiration cytology for sentinel node diagnostics in early-stage melanoma: a validation study.

Ultrasound-guided fine-needle aspiration cytology (US-FNAC) is used to evaluate the involvement of lymph nodes in various malignant diseases. Its value in detecting sentinel lymph node (SN) metastasis preoperatively in melanoma patients is controversial and is the subject of this study. In this prospective validation study, 91 consecutive patients with melanoma clinical stage I (n=64) and II (n=27) were examined with US-FNAC before SN biopsy from 2012 to 2014 at a tertiary center. All patients underwent lymphoscintigraphy before the US-FNAC. Lymph nodes that showed any of the Berlin morphologic criteria on ultrasonography were examined using FNAC. The median Breslow thickness of the melanomas was 1.22 mm (range: 0.47-11.5 mm). Twenty-two percent of the patients had metastases in their SNs, 90% of which were smaller than 2 mm in largest diameter. The percentages of metastases with a size more than 1 mm were 50 and 29%, respectively, in the true-positive and false-negative US groups. The sensitivity, specificity, positive predictive value, and negative predictive value for overall US examination were 30, 81, 24, and 83%, respectively. None of the FNACs contained conclusive malignant cells. The specificity of the FNAC was 76%. Our results show that US-FNAC was not a useful diagnostic tool in our setting as it did not add significantly to the staging and management of patients with mainly thin cutaneous melanomas, perhaps because of the often small size of the SN metastases. It may be useful in the early diagnosis of lymph node metastases in a subgroup of melanoma patients with larger metastases.

Health-related quality of life in melanoma patients: Impact of melanoma-related limb lymphoedema.

AIM: To explore health-related quality of life (HRQoL) in recurrence-free melanoma patients, with a focus on the association between melanoma-related limb lymphoedema and HRQoL. METHODS: HRQoL was evaluated using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ-C30), the breast cancer module (EORTC QLQ-BR23) subscales body image and future perspective, the Functional Assessment for Cancer Therapy-General subscale social/family well-being and the Hospital Anxiety and Depression Scale. Data were analysed using linear and ordinal logistic regression adjusting for age and gender. RESULTS: A total of 431 melanoma patients who had undergone wide local excision and axillary or inguinal sentinel lymph node biopsy (SLNB) and/or complete lymph node dissection (CLND) participated. No patients had had recurrence of the disease or had received adjuvant radiotherapy. The HRQoL scores improved with time after surgery. Melanoma-related limb lymphoedema was present in 109 patients (25%). Patients with lymphoedema had significantly worse HRQoL scores in the EORTC QLQ-C30 subscales global health status/quality of life, role and social functioning, fatigue, pain and financial difficulties, as well as in the QLQ-BR23 body image subscale. No associations were found between the limb affected (upper or lower limb), clinical stage of lymphoedema, duration of lymphoedema or type of surgery (SLNB or CLND) and HRQoL. We found an interaction with age and gender in the associations between lymphoedema and HRQoL: younger patients and women with lymphoedema had worse social functioning and women had significantly more impaired body image. CONCLUSIONS: The negative impact of melanoma-related limb lymphoedema on HRQoL emphasises the importance of developing strategies for increasing awareness and improving prevention and treatment of lymphoedema.

Volume and Tissue Composition Changes Measured with Dual-Energy X-Ray Absorptiometry in Melanoma-Related Limb Lymphedema.

Abstracts Background: The aim of this cross-sectional study was to investigate the volume, fat mass, and lean mass in both upper and lower limbs measured with dual-energy X-ray absorptiometry (DXA) in melanoma patients with melanoma-related limb lymphedema. METHODS AND RESULTS: Four hundred thirty-one patients who had undergone surgical treatment with wide local excision and unilateral axillary or inguinal sentinel lymph node biopsy and/or complete lymph node dissection participated in a survey, and they underwent clinical examination and measurements of their upper or lower limbs with DXA. Limb lymphedema was diagnosed on the basis of history and characteristic physical findings on the clinical examination. The inter-limb differences in volume, fat mass, and lean mass measured with DXA were categorized as none/mild, moderate, or severe according to reference values (taking handedness into account for the upper limbs). Of the 431 patients, 109 (25%) had clinical melanoma-related limb lymphedema corresponding to 23 (10%) who had undergone axillary nodal surgery and 86 (45%) who had undergone inguinal nodal surgery. The majority of patients developed lymphedema within the first year (90%) after surgery, and the majority of lymphedemas were categorized as mild. The increase in the volume of limbs with lymphedema was primarily due to an increase in fat mass. CONCLUSION: There is a high prevalence of melanoma-related limb lymphedema. The increase in volume in the limb with lymphedema is primarily due to an increase in fat mass. This increase in fat mass in limbs with lymphedema is important for the understanding of the pathophysiology and may be important in the treatment of lymphedema.

Surgical treatment of disabling conditions caused by anogenital lichen sclerosus in women: An account of surgical procedures and results, including patient satisfaction, benefits, and improvements in health-related quality of life.

BACKGROUND: Anogenital lichen sclerosus (LS), a chronic dermatitis that causes scarring and introital stenosis, may prevent sexual intercourse and reduce health-related quality of life (QoL). Surgery can restore the anatomy, allowing patients to resume their sexual lives. This study investigates outcomes in women treated with local skin flaps. METHODS: Thirty-eight consecutive LS-verified patients, surgically treated for debilitating conditions between 1990 and 2013, were retrospectively evaluated. A survey measured patient satisfaction, benefits, and health-related QoL, and the patients were also evaluated by a long-term clinical follow-up. RESULTS: In total, 33 patients (87%) experienced dyspareunia, 24 of whom could not perform coitus. At mean short-term follow-up (10.0 months), only five patients (15%) reported dyspareunia; for seven patients, the outcome was unknown. The survey response rate was 87%, and the mean time from treatment to response was 7.6 years. Twenty of 24 patients reported dyspareunia. Seventy-five percent of patients with preoperative dyspareunia reported a surgical benefit, 74% were satisfied/very satisfied with the cosmetic and overall results, respectively, and 58% reported that surgery had improved their sexual lives. The mean long-term clinical follow-up was 8.4 years. The follow-up rate was 78%. The main reason for recurrent dyspareunia was minor LS relapse (50%); these patients were still able to have coitus, and dyspareunia was reported as considerably minor compared to before surgery; 38% had more severe LS relapse, resulting in apareunia. CONCLUSIONS: Surgery for LS sequelae provides acceptable short-term functional results, enabling patients to resume coitus, with high patient satisfaction reported. However, the chronic relapsing nature of LS consequently provides varying and often short-term coital improvements following surgery.

Quantifying Long-Term Retention of Excised Fat Grafts: A Longitudinal, Retrospective Cohort Study of 108 Patients Followed for Up to 8.4 Years.

BACKGROUND: Predicting the degree of fat graft retention is essential when planning reconstruction or augmentation with free fat grafting. Most surgeons observe volume loss over time after fat grafting; however, the portion lost to resorption after surgery is still poorly defined, and the time to reach steady state is unknown. METHODS: The authors compiled a retrospective, longitudinal cohort of patients with vestibular schwannoma who had undergone ablative surgery and reconstruction with excised fat between the years 2006 and 2015. Fat volume retention was quantified by computed tomography and magnetic resonance imaging and used to model a graft retention trajectory and determine the volumetric steady state. In addition, the authors evaluated the association between graft retention and secondary characteristics, such as sex and transplant volume. RESULTS: A total of 108 patients were included. The average baseline graft volume was 18.1 ± 4.8 ml. The average time to reach steady state was 806 days after transplantation. By this time, the average fat graft retention was 50.6 percent (95 percent CI, 46.4 to 54.7 percent). No statistically significant association was found between baseline graft volume and retention. Fat graft retention over time was significantly higher in men than in women (57.7 percent versus 44.5 percent; p < 0.001). CONCLUSIONS: The authors' data provide evidence that the time to reach fat graft volumetric steady state is considerably longer than previously expected. Fat grafts continue to shrink long after the initial hypoxia-induced tissue necrosis has been cleared, thus indicating that factors other than blood supply may be more influential for fat graft retention. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Overcoming the bottleneck of platelet lysate supply in large-scale clinical expansion of adipose-derived stem cells: A comparison of fresh versus three types of platelet lysates from outdated buffy coat-derived platelet concentrates.

BACKGROUND: Platelet lysates (PL) represent a promising replacement for xenogenic growth supplement for adipose-derived stem cell (ASC) expansions. However, fresh platelets from human blood donors are not clinically feasible for large-scale cell expansion based on their limited supply. Therefore, we tested PLs prepared via three methods from outdated buffy coat-derived platelet concentrates (PCs) to establish an efficient and feasible expansion of ASCs for clinical use. METHODS: PLs were prepared by the freeze-thaw method from freshly drawn platelets or from outdated buffy coat-derived PCs stored in the platelet additive solution, InterSol. Three types of PLs were prepared from outdated PCs with platelets suspended in either (1) InterSol (not manipulated), (2) InterSol + supplemented with plasma or (3) plasma alone (InterSol removed). Using these PLs, we compared ASC population doubling time, cell yield, differentiation potential and cell surface markers. Gene expression profiles were analyzed using microarray assays, and growth factor concentrations in the cell culture medium were measured using enzyme-linked immunosorbent assay (ELISA). RESULTS: Of the three PL compositions produced from outdated PCs, removal of Intersol and resuspension in plasma prior to the first freezing process was overall the best. This specific outdated PL induced ASC growth kinetics, surface markers, plastic adherence and differentiation potentials comparable with PL from fresh platelets. ASCs expanded in PL from fresh versus outdated PCs exhibited different expressions of 17 overlapping genes, of which 10 were involved in cellular proliferation, although not significantly reflected by cell growth. Only minor differences in growth factor turnover were observed. CONCLUSION: PLs from outdated platelets may be an efficient and reliable source of human growth supplement allowing for large-scale ASC expansion for clinical use.

Avoiding a Systematic Error in Assessing Fat Graft Survival in the Breast with Repeated Magnetic Resonance Imaging.

Several techniques for measuring breast volume (BV) are based on examining the breast on magnetic resonance imaging. However, when techniques designed to measure total BV are used to quantify BV changes, for example, after fat grafting, a systematic error is introduced because BV changes lead to contour alterations of the breast. The volume of the altered breast includes not only the injected volume but also tissue previously surrounding the breast. Therefore, the quantitative difference in BV before and after augmentation will differ from the injected volume. Here, we present a new technique to measure BV changes that compensates for this systematic error by defining the boundaries of the breast to immovable osseous pointers. This approach avoids the misinterpretation of tissue included within the expanded boundaries as graft tissue. This new method of analysis may be a reliable tool for assessing BV changes to determine fat graft retention and may be useful for evaluating and comparing available surgical techniques for breast augmentation and reconstruction using fat grafting.