Dr Arthur Tjandra of Elixir de Vie was the first surgeon to start performing autologous fat grafting breasts augmentation in South East Asia, back in 2008. Other surgeons in the region followed suit from early 2010s onward, after observing the good results he published on his website as case studies. Prior to that, autologous fat grafting to healthy breasts for cosmetic/aesthetic reason was still a controversy, even in the United States. He subsequently published thousands of videos of the result of autologous fat grafting breasts augmentation on his YouTube channel. When YouTube deleted hundreds of his videos and terminated his YouTube account, he continued to upload thousands of videos to his Video Blog/Vlog. This proves that autologous fat grafting breasts augmentation is an extremely safe procedure if performed by a skilled and experienced surgeon.

From December 2008 to March 2019, Dr Arthur Tjandra of Elixir de Vie has performed more than 3,000 cases of autologous fat grafting to breasts. There were 3 cases of fat necrosis out of those approx. 3,300 cases, a mere 0.09% incidence, which means that out of every 1,000 patients undergoing fat grafting to breasts by Dr Arthur Tjandra of Elixir de Vie, there is a risk of 1 patient getting fat necrosis. None of his patients had lumps or cysts in the breasts after fat grafting. The fat retention rate is average 95% after 1 year, 90% after 3 years, and 85% after 5 years.

Why do more and more women opt for autologous fat grafting than implants?

Because over the decades, more and more women with breasts implants have reported a condition called breast implant illness which can be debilitating and affect one’s quality of life. There have been many cases of women who became suicidal because of this.

Besides this, researchers have also identified a possible association between breast implants and the development of breast-implant associated anaplastic large cell lymphoma (BIA-ALCL), an uncommon cancer of the immune system. The US Food and Drug Administration (FDA) believes that women with breast implants that have textured surfaces have increased risk of developing BIA-ALCL

On 27 October 2021, the FDA added new labeling requirement on all approved breast implants to warn patients of the risks of breast implants.

What is autologous fat grafting breasts augmentation?

It is a procedure where unwanted, stubborn fat from one area of the body is taken out, processed, then injected into the breasts to increase the size of the breasts. It can also be injected to many other areas in the body, including forehead, nose bridge, temples, chin, penis, labia majora, vaginal canal and buttocks. Dr Arthur Tjandra of Elixir de Vie is probably the only surgeon in the world who has performed fat grafting to the calves of a bodybuilder with good result.

What makes Dr Arthur Tjandra’s method special/different from other surgeons?

Although all surgeons perform fat grafting by going through the same 3 steps, the method they use in each step of the process determines the outcome and rate of fat survival/retention, as well as complications. These 3 steps are: fat harvesting/liposuction, fat processing, and fat injection.

  1. Fat harvesting/liposuction   

By performing liposuction with only a small 10-cc plastic syringe and special harvesting cannula which prevents damage/injury to fat cells, Dr Arthur Tjandra of Elixir de Vie ensures there is as little damage to fat cells as possible when they are being aspirated out. Most surgeons perform liposuction with either powered suction which generates high pressure to aspirate fat, or ultrasound-assisted device, such as VASER, which generates heat to melt the fat, before aspirating it out with powered-suction. This essentially “kills” the fat cells! Injecting dead fat cells into the breasts will not provide desirable result, and may in fact, results in complications!

  1. Fat processing

Many surgeons still use the outdated method of centrifuging their fat to purify it! Spinning fat cells at the speed of up to 20,000 RPM (revolutions per minute), depending on the type of centrifuge device, is going to kill the fat cells! Try spin yourself at the speed of just 100 rounds per minute and see what happens to you! Dr Arthur Tjandra of Elixir de Vie started performing fat grafting using this method of fat purification in the 2000s, but abandoned it long time ago.

  1. Fat injection 

This is basically the procedure of “organ transplantation” where purified fat is being “transplanted” into its new environment. Whether or not these newly-transplanted fat cells survive in their new environment depends largely on 3 factors: availability of space, availability of blood vessels and method of injection.

Preparation of the breasts by using breasts pumps for a few hours daily for at least one month prior to fat grafting procedure may loosen up the breast tissues, hence allowing more fat to be injected. It also may increase new blood vessels formation. Blood supply is the single most important factor in fat survival. Fat cells are living cells which need blood, oxygen and nutrients to stay alive.

Excellent injection technique by injecting fat in multiple small aliquots, a.k.a. micro-droplet injection in layered fashion, ensures that all injected fat cells are exposed to blood vessels. If large volume of fat is injected, resulting in “fat lakes”, blood vessels and blood supply can never reach the fat cells in the middle of the lakes. All fat cells, other than the ones at the peripheries of the lakes, are going to die, resulting in fat necrosis. It may also result in cyst formation. For this reason, Dr Arthur Tjandra of Elixir de Vie always recommends his patients to undergo multiple sessions of small volume fat injection, instead of just one session of large volume injection.

But there are many surgeons who encourage patients to undergo large volume fat injection, and even promising result of 2 cup increase in size with just 1 session!

Yes, many surgeons do that, but that does not mean it is the right thing to do. It is indeed possible to increase breast size by 1 or even 2 cup size with just one session of fat injection, by banking in from the complication of large volume injection! As most patients only want big breasts without the desire to understand how this is achieved, or the intelligence to understand the most basic requirement of a successful fat grafting, which is blood supply, a lot of surgeons just give them what they want without feeling the need to explain to them in great detail. You want big breasts, I shall just give you big breasts, right?

Let us first take a look at a simplified breast anatomy to understand the concept of making use of complication of fat grafting to make the breasts big.

Now, lets learn how and where exactly in the breasts Dr Arthur Tjandra of Elixir de Vie injects the fat. Inside the breasts glands? Below the glands? Above the glands? In the muscles? Above the muscles? Where exactly? The breasts are such big anatomical structure!

As micro-calcification is a well-recognized complication of fat grafting, Dr Arthur Tjandra of Elixir de Vie only injects fat in the upper fat layer close to the skin. He avoids injecting fat deeply. Micro-calcification is not harmful. It in fact, cannot be felt, or does it any symptoms. It can only be detected when one goes for x-ray/mammogram. The issue with micro-calcification caused by fat grafting is that it may cause confusion to the interpreting radiologist who may find it hard to differentiate from micro-calcification caused by early breast cancer. By injecting fat only in the top fatty layer of the breasts, Dr Arthur Tjandra of Elixir de Vie makes it easier for radiologist to interpret the finding of micro-calcification should it be detected during mammogram in the future. A 3D mammogram can easily show where this calcification is located, whether it is superficial or it is deep-seated, among the lobules of breast glands. By ensuring that he never injects into deeper structure, any abnormality in deeper fat layer and glands found on mammogram, warrants further investigation as it is definitely not caused by fat injection procedure. If microcalcification is found in the upper fatty layer close to the skin, it can safely be ignored, as breast cancer almost never arise from the top fatty layer of the breasts! Even if the radiologist thinks that it needs to be investigated, it is so much easier to reach.

Now, issue may arise when a surgeon injects fat all over the breasts, including all the deeper structure. When multiple micro-calcifications are detected on mammogram in the future, it is very hard to determine which ones are caused by fat injection, which are harmless, and which are the ones which warrant further investigation as they may represent early breast cancer! The problem with taking biopsy from each and every single micro-calcification you see on mammogram, especially deep-seated micro-calcification which is difficult to localize, is it is going to be extremely costly! Unfortunately, as fat injection has been done to the breasts, and fat injection is a recognized cause of micro-calcification in the breasts, your health insurance is not going to cover for any cost incurred from the investigations of these micro-calcifications!

When a surgeon injects large amount of fat into the breasts, he has no choice but to inject the fat all over the breasts, all the way from more superficial, to the deepest structures, including into all spaces in between the breasts glands. When large amount of fat is being injected, it is inevitable that “fat lakes” or “fat pools” are going to form, which may lead to fat necrosis or cyst formation. Fat necrosis or cyst formation in the deeper structures often become encapsulated, by the body’s own natural reaction to isolate this dead tissue from the surrounding healthy tissue, by forming a capsule around it. It may also become calcified. If fat necrosis occurs in the more superficial layer, the body will try to push this dead fat out, when it becomes liquefied, by moving it closer and closer to the skin, before eventually “popping” out, the way acne on your face “pop out”. But, for dead fat located deep inside the breasts glands, there is no way for the body to push and pop it out!

Surgeons who dare to promise and even guarantee a huge increase in breast size which is permanent, after just one session of fat grafting, is actually banking in from the complication of cyst formation, encapsulated cyst or/and calcified cyst to produce the effect they want, without explaining to patients how they can promise and guarantee such result when other surgeons tell their patients that result of fat grafting is unpredictable as fat resorption may occur. So, at the end, yes, their patients are going to have big breasts, but their breasts are lumpy!

Normal breast vs. fibrocystic breast
Image credit: Mayo Clinic

At the end of day, you have to ask yourself whether you want breasts which are big, but are lumpy inside, or you want big breasts which feel natural and are made up of natural and live fat cells instead of lumps of cysts, calcification, and dead fat cells. If you do not mind lumpy breasts made up of cysts, as long as they are big, you may go ahead and get large volume injection done in just one session. Otherwise, it is best to go for staged procedures, with multiple sessions of fat grafting done. It is possible to increase from A to C, D or even E cups by undergoing multiple, staged fat grafting procedures, as Dr Arthur Tjandra of Elixir de Vie has shown in his Vlog Case Studies.

From business strategy point of view, patients are more likely to choose a surgeon who promises huge increase in breast size with just one session of fat grafting. Most patients do not care about the method, or how this could even be achieved taking into consideration the fact that fat cells are living cells, and they need blood supply to survive. Many surgeons who perform large volume fat injection conveniently “forget” to advise their patients that the increase in breast size they guarantee, is caused by cyst formations and calcification deep inside the breasts, which will cause lumpy breasts. They do nothing wrong. They tell patients they can inject 300 cc of fat into each breast, and they guarantee that there will definitely be increase in breast size, with no fat resorption! They deliver their promise. What they never tell is that the amount of fat they inject is so much that it is not even possible for the body to reabsorb the fat anymore if the fat cells die. The fat cells will just die because they do not receive blood supplies, and form cysts, which eventually become calcified, forming hard lumps deep inside the breasts. As the body has no capability of breaking down these calcified cysts, they become permanent “breast implants”. It is in fact, an ingenious method of breast augmentation!

But I still want large volume fat injection. I am willing to use lumps of dead fat cells to augment my breasts, instead of living fat cells. Is there anyway to hide the lumps of dead fat cells?

Certainly! If injection is done deep inside the breasts, under the breasts glands, just above the pectorals muscles, the lumps most likely cannot be felt. This is the same plane where breast implants are placed. However, we do not know the implications of leaving these lumps of dead fat cells in the breasts over long term period, 30, 40 or 50 years from now, as surgeons all over the world only began to perform fat grafting for breasts augmentation in the mid-2000s. For this reason, Dr Arthur Tjandra of Elixir de Vie prefers a more natural way of augmenting the breasts, by blending injected fat with existing fat in the breasts. With his technique and plane of injection, which is in the fatty layer of the breasts, above the breasts glands, there is no way to tell the difference between original breasts and breasts which have been augmented with fat injection, even if an MRI is done, except for theoretically possible micro-calcifications. Having said this, quite a number of his post-fat injection patients have gone for mammogram and ultrasound, and none of them has micro-calcifications or even cysts!

One should understand that under no circumstances should dead cells be retained in the body, because these serve as growth media for bacteria. Once bacteria get inside, there would be extremely nasty infection! Hence, Dr Arthur Tjandra of Elixir de Vie does not recommend using this technique of purposely injecting large volume of fat, knowing that they will not survive and the body will not be able to reabsorb such large volume of dead tissue, and using this large lake of dead fat which will eventually form cysts and become encapsulated, to augment the breasts. This is ethically NOT right, although it gives patients exactly what they are looking for: enlarging their breasts by 2-3 cups with just one session of fat grafting!

What are the possible complications of autologous fat grafting to breasts?

There are quite a few possibilities, among others:

  1. Fat necrosis
  2. Calcification
  3. Formation of encapsulated fatty masses (cystic lesions)
  4. Lymphadenopathy
  5. Disfigurement of breast contouring
  6. Hypersensitive breasts
  7. Itchy nipples

Fat necrosis appears as painful swelling and redness on the skin if fat is injected in the upper fatty layer. If injected very deep inside the breasts, no symptom and sign can be seen on the skin. Fat necrosis is initially treated with antibiotic. If it does not resolve, the necrotic fat needs to be evacuated completely, failing which, infection may ensue. This is also one of the reasons why Dr Arthur Tjandra of Elixir de Vie does not like to inject fat deeply into the breast glands, because if fat necrosis occurs, it is much easier to evacuate all the necrotic fat as it is closer to the skin.

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