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With fat grafting gaining more attention these days for its more “natural” abilities to boost breast volume, I have seen an increasing number of my Seattle-based patients inquire during consultation about the procedure of fat grafting and whether or not they are good candidates for it. While patients tend to think of fat grafting and implant-based augmentations as either/or, there are many situations where fat grafting and an implant-based augmentation can be complementary and work in conjunction with one another to create the ideal breast augmentation result. In this plastic surgery blog post, I will review how I think about fat grafting for breast procedures, who is and is nor a good surgical candidate, and the most common scenarios I utilize fat grafting in my Seattle-based plastic surgery practice.
How Fat Grafting Works
Before getting into the details of when to best use fat grafting, it is imperative that patients have a good understanding of how fat grafting is performed and how it works. In its most basic form, fat grafting is taking fat from one area of the body and placing it in another (in this case the breast). Fat is harvested through liposuction, then separated from other blood and tissue components, and finally injected into the desired location through small incisions. Fat grafting should be thought of more like fat transplanting, where each fat cell transferred needs to establish its own blood supply in order to survive in the long run. Therefore, there is a natural decrease in the amount of fat placed initially at the time of surgery versus the amount of fat that survives in the long run. Typically, we quote about a 50-70% survival rate with grafting, making over-filling during the initial fat transfer a common practice. Factors that can affect fat grafting are often factors that affect a healthy fat cell’s ability to establish its own successful blood supply– the health of the cell, damage to the fat cell during harvest/processing/grafting, and pressure to the fat cell both immediately after grafting and in the first few months postoperatively.
Technique matters when it comes to fat grafting. When placing the grafted fat in the tissue, the goal is to spread the fat in thin layers throughout each layer of tissue in order to maximize each cell’s potential for vascular ingrowth and thus long-term survival. If you just dump a whole bunch of fat into a blob in the center of the breast (as many people think you can), all those fat cells in the middle of the blob have no chance of developing a blood supply and will just die. This can lead to the development of fat necrosis, oil cysts and less than ideal results for patients. For this reason, I believe that fat grafting should not be considered a one-to-one replacement when compared to an implant-based breast augmentation.
Who is a Candidate For Fat Grafting?
Technically, anyone with fat available for harvesting is a candidate for fat transfer. However, the more important question is rather how much fat we will anticipate needing in order to reach a patient’s desired plastic surgery outcome. One of the most common scenarios I encounter in my Seattle plastic surgery practice is a thin patient who desires a relatively large volume of fat grafting. In most of these cases, these patients simply do not have enough fat to reach their desired aesthetic goals. While we may be able to find fat somewhere, the volume (especially considering the need to overfill in anticipation for graft loss) is typically just not sufficient.
Another consideration is the quality of fat to graft. While purely anecdotal, I have found that very fit patients tend to have more fibrous fat. Fibrous fat tends to be harder to graft and thus less successful in terms of outcomes.
The recipient site (i.e. the breast for the sake of this blog post) must have enough skin stretch to be able to accommodate the desired volume of the fat grafting without placing too much pressure on the newly grafted fat cells. Patients with relatively flat chests don’t always have the skin stretch to accommodate larger volumes of fat grafting in a single session, in which case serial fat grafting may offer the best option.
Ultimately, when a patient is considering fat grafting, it warrants a long and thorough consultation to discuss the pros and cons of fat grafting, the limitations (if any) of a patient’s anatomy, and to set realistic expectations not only for the initial surgery but also for the possibility of needing future fat grafting sessions. Patient selection is key to success with fat grafting procedures since, once again, fat grafting isn’t an equal swap for an implant-based augmentation.
Why Consider Both A Breast Implant & Fat Grafting?
Implant-based breast augmentation is the most reliable way we have to add long-term volume to a breast. As it stands today, I regret to inform readers that fat grating is simply not a one-to-one equivalent to breast implants. This does not mean it cannot be used for this purpose, but it should be used judiciously and in the right patient with the right expectations and goals. Fat grafting, however, can be an incredibly useful tool to help shape the breast. This is true even in the face of using a breast implant simultaneously. Below are the two most common scenarios where I utilize both procedures in my plastic surgery practice:
To help supply extra coverage over a subfascial or subglandular implant. The primary benefit of placing a breast implant under the pectoralis major muscle is additional coverage over the implant, especially at the upper pole of the breast which tends to have less breast tissue. For many reasons, a patient may desire a breast implant be placed above the muscle, despite lacking appropriate soft tissue coverage over the implant. In this case, we worry about creating an unnatural step off at the junction of the upper chest and the breast implant. Here, even a small amount of fat grafting can be helpful to thicken up the upper pole of the breast and create a more natural look to a subglandular or subfascial breast augmentation.
To help add additional volume in the medial, or “cleavage” portion of the breasts. While many patients think that an implant alone will give them cleavage, there are actually many factors that determine how much, if any, cleavage a patient can achieve with a breast augmentation. The breast footprint is the most important determinant of this– it serves as the foundation of the house. Some patients have a wide-spaced footprint such that no reasonable volume of implant will give them meaningful cleavage without the use of a push up bra. In patients where cleavage is unlikely with an implant alone, fat grafting can be an excellent addition to a breast augmentation to help patients reach their aesthetic goals.
Individual Surgical Planning is Key
At the end of the day, surgical planning should be tailored to a patient’s unique anatomy and their individualized aesthetic plastic surgery goals. While implant-based breast augmentation is a tried and true method for enhancing breast volume, fat grafting is a critical tool we now have in our toolbox to help some patients achieve a more natural look and desirable outcome.
Dr. Megan Dreveskracht is a Female Plastic Surgeon in Seattle, Washington who specializes in Aesthetic Surgeries of the Breast, Body & Face. To schedule your consultation, call 206.860.5582 or fill out a contact form here.
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