I had an interesting conversation with a patient last week about fat transfer.

What this conversation made quite clear to me was that there is an ongoing misunderstanding of what fat transfer is and can achieve in the context of breast reconstruction, which is probably being perpetuated online.

The question of what we can do with fat transfer alone remains a rather vexed one. There is a significant community (in online forums and closed groups) of women discussing their respective experiences of breast cancer, breast reconstruction, and the often wildly variable information they have received from their treating clinicians. In this case, a lady came to see me to discuss having her reconstructive breast implants removed and replaced with fat based on information within an online group.

This lady's story (leading up to seeing me) is obviously very similar to many other women, and it is one I hear frequently. It goes a bit like this: diagnosis as a young woman, rushed through referrals to a general surgeon, a basic mastectomy is performed (without ever discussing or referring for consideration of reconstruction) leaving her flat, then post-op chemotherapy, and then a staged implant-based reconstruction (also with a general surgeon) which isn't a great experience, and is associated with all the usual issues that we see associated with subpectoral implants and delayed implant-based reconstruction. Ultimately, the issues with those implants are then compounded by concerns associated with the issue of "breast implant illness" and there is a desire expressed to have the implants removed.

Hence, this lady found her way to me to discuss fat "transfer", based on information from her online group. This is kind of where it gets a little tricky.

The first question is this: can fat transfer alone ever create a 'total' breast reconstruction? 

The second question is: are people getting confused by information online between fat transfer (as a graft), and transferring fat (as a vascularised flap eg. a DIEP flap), in their search for an "autologous" reconstruction?

So I figured it would be useful (maybe?) to consider these questions and present some sort of outline of the limits and possibilities of fat grafting in the context of breast reconstruction.

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Righto, firstly then, can we make a breast, in its entirety, just by squirting fat into what is left after a mastectomy?

Well, it depends. There is an answer that has a hell of a lot of ifs and maybes.

So I'll answer the question by outlining the very strict conditions that would need to be met (in my opinion) for fat graft (as opposed to a flap) to work for a total breast reconstruction, on its own.

Total breast reconstruction with fat graft

Is only possible if:

1. a woman has a small breast before mastectomy

Fat transfer will never be able to reconstruct a breast of similar size to what can be achieved with an implant, or a flap. Whilst we can create an additive effect with repeated sessions (see below), there will be a limit to what is possible. I would suggest that any more than a full A cup (maybe a small B if bloody lucky) after mastectomy would be unlikely, and if expectations are beyond this, then this is the wrong technique to be thinking about.

2. the mastectomy is at least skin-sparing, but ideally nipple-sparing

If the general surgeon doing mastectomy removes the breast skin and leaves a patient "flat" then this creates both a restricting scar and a total loss of breast shape and structure. In this situation, without something that can itself recreate a breast shape (like an implant or a flap), the fat transfer will simply not work the way we want.

3. the infra-mammary crease is properly preserved by the breast surgeon during mastectomy

The breast crease is the single most important anatomical feature of the breast (assuming condition 2 has been met) when it comes to allowing a natural breast reconstruction. If that crease has been destroyed by the surgeon performing the mastectomy, we would have to surgically recreate it before any technique of reconstruction, including fat transfer, would work.

4. the mastectomy does not leave behind "superthin" mastectomy flaps

Any fat injection in a total breast reconstruction is into the fat layer just under the skin. If the mastectomy does not leave sufficient tissue thickness behind, then there simply won't be sufficient space into which we can inject the fat.

5. if an implant has been used, it is modest in size

The context of this discussion, which is the reversal of a previous implant reconstruction, adds complication. An implant reconstruction would have several effects that we have to manage if considering whether fat transfer on its own could be used. The single most obvious issue is the fact that an implant will nearly always make a breast that is bigger than what can be achieved with fat transfer. The larger the implant, the more "excess", stretched skin there will be that needs to be managed. The other issues with an implant are the presence of the implant capsule (which will need to be removed), and the typical violation of the breast boundaries (which need to be recreated).

6. a woman is prepared to accept a period of not having a breast mound

No matter which way we look at this, to allow a total breast reconstruction with fat transfer, a period of not having a breast is required. Either the breast is modest enough that a mastectomy can be performed and then the breast skin is simply allowed to heal back down onto the chest wall without the risk of scar distortion (the bigger the breast, the more likely scar distortion will be), or if an implant reconstruction has previously been performed, the implant needs to be removed (with the capsule) and the breast needs to be tightened and minimised to remove any skin excess and then allowed to heal onto the underlying chest wall/muscle. How the breast is managed to allow a relatively flat chest without issues relating to fluid collections, scar distortion or contour deformity is absolutely vital.

The point here is that fat transfer can only be done the way it would need to for a total breast reconstruction if there is no space left within (what is left of) the breast after mastectomy. The skin all needs to heal down onto the chest wall before we can then expect the fat transfer to work in rebuilding a 3 dimensional breast shape.

After approximately 3 months, the first round of fat transfer can then be performed.

7. a woman is prepared to accept multiple operations (typically 3-4) separated by about 3 months between each.

This one is the kicker. It is exceedingly rare that women are prepared to accept the length of time and multiple operations required for this technique to work. I think that in most cases, 3-4 procedures would be required. I also think that if we cannot achieve a result in 4 operations at most, then this technique SHOULD NOT BE ATTEMPTED.

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Fat transfer CANNOT:

1. reconstruct a breast in its entirety at the same time as a mastectomy

2. reconstruct a breast in less than 3 sessions of fat transfer

3. reconstruct a breast if there are not well defined and preserved breast boundaries after mastectomy

4. reconstruct a breast in its entirety if THERE HAS BEEN A SIMPLE MASTECTOMY (ie. if skin has been aggressively removed and a woman is left flat with long horizontal scars), rather than a skin or nipple-sparing mastectomy.

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So, is it even worth considering?

Honestly, I'm not sure it is worth it for most women.

We get a far better result with a DIEP flap, at the expense of a donor site.

We get a more reliable volume with an implant, at the expense of, well, an implant.

But in very carefully selected small breasted women, fat graft can be used on its own for a breast reconstruction in its entirety. But it demands a great deal from a patient for a relatively limited outcome. Multiple operations (and the associated costs), time, and a degree of unpredictability. It's a bit of an ask, which is why it's so uncommon in Australia.

And before anyone asks: no, Brava (IYKYK) is not available for Australian patients, and I am not sure I would recommend it even if it was.

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The lady whose conversation with me sparked this article wanted to know why I didn't have more photos of people like her (simple mastectomy followed by 2 stage delayed implant reconstruction) who had converted to a total fat graft reconstruction. Pretty simple answer to that question: it just isn't something that most patients or surgeons think is worthwhile. Most ladies who want to get rid of their implants choose a DIEP flap, or something similar.

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Which brings me back to something I said at the start.

I get the feeling that there is a misunderstanding in some of the private groups/forums online about the difference between fat grafting, and using abdominal fat as a flap, when it comes to breast reconstruction. Maybe there are people discussing "fat grafting" to replace their implants, when in fact they mean something like a DIEP flap. This then gets picked up by another patient, and the misunderstanding spreads.

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I hope this is useful. If there are any questions, please feel free to get in touch.

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