Using Fat Grafting for Breast Reconstruction

By Constance M. Chen, MD, MPH

Fat grafting is an innovative form of breast reconstruction that avoids both the artificiality of breast implants and the scarring and complexities of flap surgery. A form of natural tissue breast reconstruction, fat grafting is an option for women with the time and patience to accept its limitations.

The most common type of breast reconstruction involves tissue expanders and breast implants. Recent FDA warnings about breast implant safety, however, have left increasing numbers of women wary about placing a foreign object in their body. In addition to traditional concerns about capsular contracture, infection, and implant rupture, women are discouraged by reports of Breast Implant Illness, Breast Implant Associated-Anaplastic Large Cell Lymphoma, and even Breast Implant Associated-Squamous Cell Carcinoma. While breast implants are the simplest type of breast reconstruction, they look and feel artificial, and women understandably worry about the autoimmune effects and the possibility of various cancers of the immune system that can be associated with breast implants.

The alternative to implant-based breast reconstruction is natural tissue breast reconstruction. Usually, women who want breast reconstruction without implants are offered some type of flap surgery. Traditional muscle flaps, however, like the TRAM and latissimus dorsi flap sacrifice functional muscle that can cause abdominal bulges and weakness in the case of the TRAM – which violates the abdominal wall integrity – and make it hard to climb ladders and swim in the case of the latissimus dorsi flap – which cuts out a major back muscle. Perforator flap breast reconstruction is often considered the gold standard in breast reconstruction since it preserves the muscle, but it is a long complex operation that still leaves long visible scars at the donor sites and requires a microvascular surgeon.

For women who want natural tissue breast reconstruction but cannot or do not want to undergo flap surgery, another option is fat grafting. One reason a woman might not be a candidate for flap surgery is due to a clotting disorder that will cut off the blood supply to the flap. Or she may be a smoker or a user of nicotine in another form, which significantly increases the risk of flap failure, wound healing problems, and infection. Other recreational drugs, such as cocaine, will also prevent a successful flap surgery. Or a woman may have significant medical comorbidities that can make a long operation unsafe such as obesity, diabetes, or heart or lung issues. Finally, some women may simply not want the extensive scars that come with cutting out tissue from one part of the body and transferring it to the chest to create a breast.

Fat grafting involves liposuction of one area of the body, processing the lipoaspirate to remove impurities, and transferring the purified fat cells to the chest to create a breast. Fat cells must be processed to remove components such as blood, plasma, and oil in order to improve fat take. There are three different methods of processing lipoaspirate. The first method is by centrifuge. The second is by washing the fat cells in a closed system. And the third method is by filtering the fat through gauze. Studies have indicated that each method is equally effective in purifying the fat.

The problem with fat grafting is that unlike flap surgery, the transferred fat has no blood supply, and depends on nutrients passively diffusing through the fat cell wall by osmosis to survive. On average, only 30-70% of the fat cells transferred will survive, and only a limited amount of fat can be transferred in each session to maximize fat cell survival. Fat cells need to be within a millimeter from a blood vessel and cannot be injected to fill a large empty space. The amount of fat that will survive is unpredictable, and it takes several months to know how much of the transferred fat is resorbed.

Fat grafting is a slow, layered process that requires patience. Building up a breast from a flat chest will take multiple sessions, which can take months or even years. In addition, if the woman does not have a lot of spare fat, there are limitations to how much fat can be harvested. And generally the thinner the patient, the more uncomfortable the liposuction harvest will be. While fat grafting is an outpatient procedure, your recovery time will depend on how much fat is harvested and from where.

Some surgeons will use adjunct devices such as a BRAVA suction cup or a lotus mesh implant in an effort to speed up and improve the results of fat grafting. Since none of the adjunct devices are FDA approved or proven to be effective, however, they are essentially considered experimental and not covered by insurance.

What to expect  

Since fat grafting is so unpredictable, fat grafting is most commonly used to improve imperfections such as contour irregularities in the breast after flap reconstruction or differences in breast size after partial mastectomy, lumpectomy, or excisional breast biopsy. While fat grafting can be used to build an entirely new breast from a completely flat chest after mastectomy, patients need to understand the limitations of the procedure.

If you are interested in fat grafting as part of your breast reconstruction process, ask your plastic surgeon to tell you more about the process. You may identify areas of the body for fat harvest. The most common fat donor sites are the abdomen, back, and thighs. Unlike flap surgery, the incisions for both liposuction and fat transfer are 3-5 millimeters in size, and can be camouflaged in creases. Since fat grafting is an outpatient procedure, each surgical session is shorter and simpler than with flap surgery. The downsize is that since fat “take” is unpredictable multiple sessions may be required to create a breast mound. In addition, it may be difficult if not impossible to create a very large breast.

Breast reconstruction is a process. Patience is especially crucial with fat grafting. It takes several months to see how much fat remains after each session, and it can take years for the final breast reconstruction. As long as your weight is maintained, however, the fat that survives is permanent.”

Constance M. Chen, MD, is a board-certified plastic surgeon with special expertise in the use of innovative natural techniques to optimize medical and cosmetic outcomes for women undergoing breast reconstruction. She is Clinical Assistant Professor of Surgery (Plastic Surgery) at Weill Cornell Medical College and Clinical Assistant Professor of Surgery (Plastic Surgery) at Tulane University School of Medicine. www.constancechenmd.com