Overview
Definition:
Fat grafting in breast reconstruction, also known as autologous fat transfer or lipofilling, involves harvesting adipose tissue from one part of the body (donor site) via liposuction and then injecting it into the breast to restore volume, shape, and contour
It is a versatile technique used in immediate or delayed breast reconstruction following mastectomy, correction of deformities, and aesthetic augmentation.
Epidemiology:
Increasingly utilized globally for breast reconstruction, especially in patients seeking a more natural aesthetic outcome or those unsuitable for or preferring to avoid implants
Incidence data is growing as its adoption rises in oncologic and aesthetic practices.
Clinical Significance:
Offers a potentially natural and autologous alternative to synthetic implants
It can improve the aesthetic outcome of breast reconstruction, address contour defects, and potentially offer some improvement in radiation-induced tissue changes
Understanding its technique is crucial for reconstructive surgeons preparing for DNB and NEET SS exams.
Indications
Primary Indications:
Reconstruction following mastectomy (immediate or delayed)
Correction of post-lumpectomy defects
Volume augmentation in implant-based reconstruction (e.g., covering implant edge)
Correction of deformities post-radiation therapy.
Secondary Indications:
Asymmetry correction
Treatment of lipoatrophy
Aesthetic breast augmentation in select patients.
Contraindications:
Active infection at donor or recipient site
Uncontrolled diabetes
Severe peripheral vascular disease
Significant coagulopathy
Poorly managed oncologic disease
Patient unsuitability for liposuction.
Preoperative Preparation
Patient Evaluation:
Thorough medical history and physical examination
Assessment of donor sites for adequate adipose tissue
Discussion of goals, expectations, and potential outcomes with the patient
Oncologic clearance and imaging (mammography/ultrasound/MRI) as indicated.
Donor Site Selection:
Common donor sites include the abdomen (flanks, supra- and infraumbilical), thighs (anterior, medial, lateral), and buttocks
Choice depends on patient anatomy and surgeon preference.
Recipient Site Assessment:
Evaluation of existing scar tissue, vascularity, and tissue availability
Marking of planned injection areas for consistent volume distribution.
Anesthesia Considerations:
Typically performed under local anesthesia with sedation, regional anesthesia, or general anesthesia, depending on the extent of liposuction and fat grafting
Choice is guided by patient factors and procedure complexity.
Procedure Steps
Fat Harvesting:
Gentle liposuction using a blunt cannula (e.g., 2-4 mm) with low negative pressure
Infiltration of tumescent solution (saline, lidocaine, epinephrine) to facilitate harvesting and reduce blood loss
Careful dissection to minimize trauma to adipocytes.
Fat Processing:
Post-harvesting processing is critical for fat graft survival
Common methods include decantation (allowing gravity to separate layers), centrifugation (spinning at controlled speeds to separate fat, oil, and blood), or simple washing
The goal is to obtain purified adipose tissue free of excess fluid and blood.
Fat Injection:
Injection of processed fat using small-gauge cannulas (e.g., 1-2 mm) in a multi-directional, layered, and dispersed technique
Avoidance of large boluses
Small volumes (e.g., 0.1-0.5 cc) per pass to maximize surface area for revascularization
Superficial and deep injections are often combined.
Volume Considerations:
Typically, 30-50% of the injected fat survives
Multiple sessions are often required to achieve the desired volume
Overcorrection is generally avoided due to potential fat resorption and unpredictability.
Postoperative Care
Donor Site Management:
Compression garments are applied to the donor sites for 2-4 weeks to reduce swelling, pain, and aid in skin retraction
Patients are advised to limit strenuous activity.
Recipient Site Care:
Gentle handling of the breast
Avoidance of pressure or trauma
Patients may experience bruising, swelling, and mild discomfort
Support bras may be recommended
Early mobilization is encouraged.
Follow Up Schedule:
Regular follow-up appointments at 1 week, 1 month, 3 months, 6 months, and 1 year post-procedure
Clinical and photographic assessment of graft take, symmetry, and patient satisfaction
Mammography or other imaging as indicated for surveillance.
Complications
Early Complications:
Hematoma
Seroma
Infection
Fat embolism (rare but serious)
Pain and swelling at donor and recipient sites
Uneven graft take.
Late Complications:
Fat necrosis leading to cyst formation or calcification
Scarring and contour irregularities
Asymmetry
Lumps or nodules
Graft resorption leading to volume loss
Interference with mammographic interpretation.
Prevention Strategies:
Meticulous surgical technique, including gentle fat harvesting and dispersed injection
Appropriate processing of fat
Adequate postoperative compression
Careful patient selection
Close follow-up to monitor for complications
Pre-operative and intra-operative imaging assessment.
Key Points
Exam Focus:
Key surgical steps, fat processing techniques, and understanding graft survival rates (30-50%)
Awareness of potential complications like fat necrosis and calcification, and their impact on mammography.
Clinical Pearls:
Utilize multiple small injections for optimal revascularization
Avoid overcorrection as significant resorption is expected
Multiple sessions are often necessary
Discuss realistic outcomes and the need for potential touch-up procedures with patients.
Common Mistakes:
Harvesting fat with high negative pressure, leading to adipocyte damage
Inadequate fat processing, resulting in poor graft take
Injecting large boluses of fat, leading to central necrosis
Insufficient follow-up, missing early signs of complications.