Chapter 158: Autologous Fat Grafting in Breast Reconstruction

BACKGROUND

As refinements in breast reconstruction techniques have occurred over the years, the aesthetic goals and expectations of our patients have risen. While many women are happy with their implant reconstructions following mastectomy, some voice disappointment with the aesthetics, particularly unclothed. Rippling following implant reconstructions may be improved by converting a saline implant to silicone or camouflaged by use of capsular augmentation or acellular dermis.^1-3

Sharp transition zones, particularly in the superior pole, are a frequent clue that this is an implant-based breast reconstruction. While satisfaction with autologous flap reconstructions for breast reconstruction is high, addressing some limitations of implant-based reconstruction, some may also have contour irregularities or sharp transition zones, particularly at the borders of flap inset. Lastly, deformities associated with breast conservation therapy may lead to dissatisfaction in our breast cancer survivors. One surgical technique gaining popularity and acceptance that can improve upon these contour deformities and increase patient satisfaction with their breast reconstructions is autologous fat grafting.

Many advancements in autologous fat grafting techniques have occurred since its initial use in 1893 when Neuber⁴ transferred arm fat to the orbit for the correction of an adherent, depressed scar. In 1895, Czerny⁵ was the first to use autologous fat to reconstruct a breast deformity transferring a back lipoma to replace breast tissue following removal of an adenoma. Fat injection through cannulas was described by Charles C. Miller⁶ of Chicago in 1926, advocating its use for the correction of nasolabial folds. Inconsistent rates of fat survival led to poor adoption. However, fat as an injectable experienced a rediscovery with liposuction in the 1980s.⁷ Once considered controversial, fat grafting to the breast has been refined with overall results now more predictable and reliable.⁸ Recently, the American Society of Plastic Surgeons Fat Graft Task Force issued a new statement regarding fat grafting to the breast stating, “Fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgery; however, results are dependent on technique and surgeon's expertise.”⁹ Currently, autologous fat grafting has been integrated into many plastic surgeons’ armamentarium to enhance surgical results for both reconstructive and aesthetic procedures. Improved clinical outcomes following autologous fat grafting have been increasingly appreciated by plastic surgeons and their reconstructive breast patients.

While there are numerous variations in fat grafting techniques used by surgeons, there are commonalities to all methods. Fat is harvested from a donor site through mechanical aspiration. The fat is then processed to isolate the fat for injection and the graft is placed to address the contour irregularity. Although techniques differ, most surgeons agree the ultimate success of fat grafting depends on the quality of the fat and the ability of recipient bed to revascularize the transplanted fat for definitive graft take. The quality of fat graft can be influenced by donor site as well as harvest and ...