Breast Augmentation With Primary Fat Grafting

Introduction

Breast augmentation with primary fat grafting has gained increasing popularity in the past decade. It has several advantages over implant-based breast augmentation, including avoidance of foreign body implantation and related capsular contracture, which are appealing to people who want breast augmentation using autologous tissues. Initially, the safety and efficacy of fat grafting to the breasts had been questioned. However, a position paper from the American Society of Plastic Surgery Fat Grafting Task Force in 2009 concluded that fat grafting may be considered for breast augmentation and correction of defects associated with medical conditions and previous breast surgeries.

Several authors have also advocated the safety and efficacy of fat grafting to the breasts, and limited data on the radiologic impact of fat grafting to the breasts suggest that there is minimal interference with breast cancer screening. In addition, recent advancement in the concept and techniques of fat grafting has also added incentives to the popularity of this procedure. Proper patient selection is of utmost importance for a satisfactory outcome of breast augmentation with primary fat grafting.

In this chapter, the authors describe their preferred technique for breast augmentation with fat grafting, including patient selection, preoperative consultation, and several techniques to ensure an optimal outcome. In addition, a rationalized approach to fat necrosis after fat grafting for breast augmentation and an algorithm for management of fat necrosis are also introduced.

Indications and Contraindications

A good candidate for breast augmentation with fat grafting would be the one who has an abundance of body fat to be harvested from liposuction and sufficient skin pocket dimension or pliability for accommodation of adequate volume of graft. In addition, patients who desire a volume increase of 120–150 cc are good candidates because this procedure has limitations in possible volume increase after each session of fat grafting. There is no absolute contraindication for this procedure. However, patients who do not have sufficient fat to be harvested and those who have tight, small breast skin envelopes ( Fig. 6.1 ) and are reluctant to undergo either internal or external tissue expansion are not good candidates for this procedure. Box 6.1 summarizes the considerations for a good candidate for breast augmentation with primary fat grafting.

Preoperative Evaluations and Special Considerations

Patients with a family history of breast cancer should be informed that the long-term safety of primary fat grafting to breasts has not been established in this group of patients and an extra effort in breast cancer surveillance may be needed after this procedure because of the possibility of calcification as a result of fat necrosis in the breast tissue. Fat necrosis may cause physical or psychological discomfort and potentially complicate breast cancer surveillance and should be communicated to the patient as a risk.

The volume of available fat is an important step for preoperative consultation and planning to ensure adequate volume to be harvested for single or multiple sessions of fat grafting depending on the patient’s expectation. Estimation of the volume of body fat is conveniently achieved by palm measurement in which one palm size is about 180–200 cm ² depending on the surgeon’s palm size. The thickness of fat can be determined by a pinch test. The volume of fat to be collected is calculated by the area multiplied by the estimated thickness of fat that can be suctioned (volume = palm size 200 cm ² × thickness of fat to be suctioned). In general, a total of 700–1000 cc of lipoaspirates (not including the infranatant) can be harvested from both thighs, which is enough for most patients.

The skin can be tested by finger stretching to see if it can be pulled off from the body with little resistance. Note especially the skin pliability in the lower pole, where it is most needed to be expanded for an anesthetic lower pole breast contour. If the skin envelope is tight and the original breast mound is small, then tissue expansion is necessary to overcome the skin tension to achieve the desired breast volume and shape. Tissue expansion can be either external or internal.

Patients who desire more than a two breast cup size increase should be informed of the necessity of more than one or multiple sessions of fat grafting. In patients who request breast augmentation by replacing previous breast implants with fat grafts, any breast deformity or asymmetry (e.g., capsular contracture) should be identified. If capsular contracture has developed, concomitant capsulotomy (Baker I–II) or capsulectomy (Baker III–IV) should be performed to achieve a smooth contour of the breasts ( Box 6.2 ).

Surgical Techniques

Relevant Surgical Anatomy

Injection of fat grafts to the breast requires an understanding of the relevant anatomy in this area for safety and efficacy of this operation. Fat grafts are injected in different depths of the breast mound: subcutaneous, breast tissue, under breast tissue, intra–pectoralis muscles, and subpectoral levels. Deeper to the subpectoral level lies the ribcage and intercostal muscles, and thus injection should not point down toward the thorax once the cannula is deep to subpectoral level because pneumothorax may occur once the cannula penetrates the pleura ( Fig. 6.2 ). The breasts are well-vascularized tissues and receive multiple blood supplies from several directions but mainly from perforating branches of the internal mammary artery. Therefore, gentle injection with a blunt-tipped cannula can minimize vessel injury and avoid major hematoma in the breast tissue.