Fat injections continue to grow in popularity for numerous applications. While the procedure has good acceptance in the face, its use in the breast for correction of contour deformities is still in its infancy. Its use in breast reconstruction provides another potential tool for breast shaping due to its ease of use, lack of any significant complications, and its reported longevity.
Few plastic surgeons have significant experience to date with fat grafting to the reconstructed breast. In the August 2009 issue of the journal Plastic and Reconstructive Surgery, a paper was published reporting on experiences with managing secondary breast contour problems with fat grafting. They classify reconstructive breast deformities into three types. Type 1 are step-off deformities between the chest wall and the reconstructed breast interface. Type 2 deformities are deficiencies within a flap reconstruction, usually from fat necrosis. Type 3 deformities were the result of postoperative irradiation.
The authors reviewed 110 patients who underwent fat grafting, on average, more than 6 months after reconstruction. Grafting was usually done with other ancillary reconstructive procedures. More than half of the patients (61/110) required multiple fat grafting sessions with some (8) having as many as four injection treatments. The mean volume of transplanted fat was around 30ccs. They suffered no significant complications other than a few persistent contour irregularities. Their assessment was that satisfactory contour restoration was achieved in 85% of the patients. If good contour was maintained at three months after injection, they felt the results persisted.
Two interesting areas of injection fat grafting reported was for breast implant rippling and in the breast which is to undergo radiation therapy. Thickening the subcutaneous tissue between the implant capsule and the skin in problematic rippling seems like a good idea, provided one can avoid accidental penetration of the implant. The use of fat grafting into irradiated tissue beds may not be as successful as pre-grafting before irradiation, but this report confirms what others have indicated in which the quality of the tissue bed is improved by the graft.
The success of fat grafting in reconstructed breast contour defects is illustrated in this recent report. The key is that large amounts of injected fat grafts will not work. Notice that the injected volumes were small and optimal correction was obtained when necessary by multiple injection sessions. In my Indianapolis plastic surgery practice, I tend to use more than 30ccs, often up to 75 to 100ccs. As the authors have stated, there is clearly a volume point beyond which it is detrimental to graft survival, particularly when the injections are not put into muscle. To give an edge to injected fat survival, I mix it with PRP (platelet-rich plasma) given the larger amount of fat graft volume. Also, I prefer to inject more volume for the practical reason of health insurance coverage. Fat grafting into the reconstructed breast is viewed by some insurance carriers as ‘experimental’ and not a standard treatment as of yet. Repetitive fat grafting sessions can result in insurance reviews and denial of coverage.
Dr. Barry Eppley
Indianapolis, Indiana