By Dr Simone Matousek

Fat grafting has been well established in small volumes in the face for many years. Large volume fat transfer to the breasts and also the buttocks is a more recently refined procedure.

Surgeons have been attempting fat transfer to the breast for over a century. The first documented attempt was in 1895, when a German physician (Czerny) transferred a benign fatty lump (lipoma) from a singer’s back to her breast (which had required mastectomy for chronic infection and a tumour). Other techniques followed using large lumps of fat (prior to the advent of liposuction in the 1980s), however, none gained wide acceptance. Poor techniques led to lumps and hardness in the breast and concerns that this would obscure detection of breast lumps and potentially increase cancer. Thanks to the persistence of select surgeons around the world who pioneered better techniques using centrifuging, smaller grafts (or micrografts) and the BRAVA device, the technique has now been improved, with increased survival of the fat, minimal complications and its safety with respect to breast cancer is well-documented in long term clinical trials. Removing fat from unwanted areas to the breast has become possible and is an excellent alternative or adjunct to implants in many situations.

What is fat grafting or fat transfer?

Fat grafting or transplantation takes fat from unwanted areas (liposuction) and is then centrifuged to concentrate the fat, and reinjected into the breast with small cannulae (micrografting).

A “graft” is simply a term used to describe something that is removed from one area (in this case the thigh, tummy, arms) and is not alive when it is removed, and relies on the blood supply of the site to where it has been transferred (eg the breast) in order to survive.

Fat transfer feels like a natural breast and achieves enhancement with only a few tiny scars (all less than 1cm) hidden in the creases of the breast.

Uses of fat grafting

  • Natural breast enhancement
  • Natural buttock enhancement
  • Total replacement of breast implants with fat transfer
  • To mask visible breast implants
  • Breast asymmetry
  • Constricted or tuberous breast
  • Segmental defects of the breast after lumpectomy for cancer
  • Post-mastectomy breast reconstruction
  • Radiotherapy damage, scarring and distortion of the breast

 

Advantages of fat grafting over other techniques

  • No large visible scars
  • If used alone, no implants are needed so a totally natural feel
  • Ability to reshape breasts that are constricted or tuberous (a congenital breast condition) with needle release (no scar technique)
  • Fast recovery
  • Bonus of liposuction, which removes fat from unwanted areas

 

Who is suitable for the fat grafting technique?

Most people will have adequate fat stores in certain areas of their body to enhance their breasts, even if they are slender. The best candidate for fat transplantation is someone who would like a natural looking soft breast, a subtle augmentation without scars and does not like the idea of having breast implants.

Not everyone is suitable for fat transfer; some will not have enough fat available anywhere to give them adequate breast volume. These patients are best to have implants, as liposuction in a very slender individual risks creating defects in areas where the fat has been removed.

If a small amount of lift is needed (eg post- baby, but not quite enough laxity to require a formal lift or mastopexy) then placement of an implant can provide this degree of lift which fat grafting cannot. However, once a formal lift is required to reposition the nipple, then fat transfer can be used in conjunction with this technique to increase the volume.

Breast implants remain suitable in certain situations. Most surgeons who have an interest in fat transfer to the breast still perform many breast implants. However, very thin candidates often end up having implants that are visible (especially at the top or superior surface of the implant). Although some may not have enough fat for a complete augmentation with fat alone, a small amount of fat injected in regions where the implant is visible, combined with breast implants is a good solution.

Weight changes and fat graft survival

Large changes in weight will affect the results as weight is gained and lost in an equal manner throughout the body. Therefore if weight is gained post-surgery the fat grafted breasts will enlarge; if it is lost, the breast size will reduce. Therefore, if patients are planning to lose weight, this should be done prior to surgery. Although it sounds counterintuitive, it is best for patient to be at their thinnest when they come for fat transfer surgery.

Current studies suggest with as stable weight and newer techniques of handling the fat, it will last for several years. Breasts, however, do undergo significant changes at various stages of life such as during pregnancy and menopause and volume changes in these situations cannot always be predicted.

Cancer risk and fat grafting

Studies of large numbers of patients from around the world have shown there is no increase in the risk of breast cancer. Patients are carefully monitored following surgery with MRI (Magnetic Resonance Imaging, a highly sensitive scan for detecting abnormalities in breast tissue). A pre-operative screening MRI is required for all patients. This is read by a radiologist who is very experienced in examining breast MRIs. Follow up MRIs are required for screening to ensure no changes have developed in the breast. Scientific studies have shown it is easy to identify any concerning lumps in the breast compared to the grafted fat. In fact, more abnormal areas are found after breast reduction surgery (a common procedure) and breast lump removal when compared with fat grafting.

The procedure itself

Fat transplantation techniques have significantly improved over the past decade due to more careful harvesting, handling and injection techniques for the fat.

It is centrifuged after removal, which means unnecessary fluid is removed, concentrating the fat to the most effective portion to inject. It is then injected through very fine cannulae into the breast (micrografting). It is carefully feathered and spread in multiple layers in a very precise manner in micro-droplets to ensure no lumps are created and all the fat cells have a good blood supply to survive.

Older techniques did not use these refinements; therefore in the past, the fat did not survive as well, and formed lumps.

Stem cells – do they help?

New machines are available to select out stem cells from fat, which is an exciting area of current research. Fat itself is a rich source of stem cells, and by centrifuging it alone, the amount of stem cells does increase in the injected fat.

However, currently there is insufficient evidence on the safety and efficacy of fat augmented with large numbers of stem cells by the use of devices. These are undergoing trials and although they may be used in the future, this technology is new and has little published data. None of the US or European board-certified plastic surgeons who pioneered and developed these techniques of fat grafting are using such machines as a routine.

All the large long-term published clinical trials and safety data regarding fat grafting have been done on patients with centrifuged fat, not with stem cell augmented fat.

The current method of fat grafting without adding stem cells, achieves very good results. When centrifuged fat is compared with stem cell enriched fat, studies have shown no increase in survival in the limited small numbers of trials that have been performed.

BRAVA – can a machine really increase breast size?

The BRAVA Breast Enhancement and Shaping System was invented by Dr Roger Khouri, an American plastic surgeon, to prepare the breast for grafting by pre expanding it and creating a larger space for fat grafting and a better blood supply.

Graft “take” or “survival” depends on blood supply in the recipient area ie the breast. Improving it, therefore, improves graft survival and means a greater volume of fat remains long term.

Although it appears daunting to wear such a device, most people tolerate it very well, and persist with it as they see rapid results. Many patients manage to sleep with it in place.

The BRAVA can increase breasts by one to two cup sizes over the course of about 10 weeks when worn for around 8- 10 hours a day. Much of the result gained is lost, however, if the device is no longer worn and no fat graft is placed in the space. There is some long-term permanent increase in breast volume with BRAVA alone, but it is small after cessation of use.

This means wearing BRAVA reduces the number of fat grafting sessions needed (a tight non-expanded breast is limited in how much fat can be injected into it; if too much fat is injected with inadequate space, it does not survive) and enhances survival of the transplanted fat. The BRAVA is not essential for everyone. It is particularly recommended for those with a tight breast or those who have had radiotherapy. Patients with loose breast skin (eg after multiple pregnancies or massive weight loss) or those not wanting a large augmentation (or willing to undergo more than one procedure) may not need to wear the BRAVA.

Recovery time

Patients are up and walking the day of surgery, however, with large volumes of liposuction, will remain in hospital overnight. Smaller fat graftings or touch-ups can be performed as day surgery and have little downtime. Most surgeries are performed under general anaesthesia with long acting local anaesthetic injected into all the liposuctioned areas to ensure patients are as comfortable as possible post-operatively.

A firm garment needs to be worn for 6 weeks following liposuction to minimise bruising, swelling and contour irregularities. These are skin tight and can be worn under clothes without being very visible.

There will only be very light dressings on the breasts where the cannula entry points for injection have been placed and small dressings over the liposuction cannula entry points. Bruising varies from patient to patient but should resolve in most by 2 weeks.

At the moment, studies show a range of 60-80% grafted fat survives (so overcorrection is required). There is evidence for greater survival when the BRAVA device is used. Once the graft has stabilized at around 6 weeks, the volume increase should be permanent provided the patient’s weight remains stable.

Dr Simone Matousek

Dr Simone Matousek is one of a few surgeons in Australia currently performing large volume fat transfer to the breast. After completing fellowships in both breast and facial aesthetic surgery, Dr Matousek visited Dr Roger Khouri, who pioneered the technique of breast fat transplantation, and undertook his advanced course in fat grafting in Miami. Her practice, Potts Point Plastic Surgery, is located in the grounds of St Luke's hospital in Sydney. She is an active member of the international federation of adipose therapeutics (iFATS), the Australian Society of Plastic Surgeons (ASPS) and the Australasian Society of Aesthetic Plastic Surgery).

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