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.
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.
Is only possible if:
1. a woman has a small breast before mastectomy
2. the mastectomy is at least skin-sparing, but ideally nipple-sparing
3. the infra-mammary crease is properly preserved by the breast surgeon during mastectomy
4. the mastectomy does not leave behind "superthin" mastectomy flaps
5. if an implant has been used, it is modest in size
6. a woman is prepared to accept a period of not having a breast mound
7. a woman is prepared to accept multiple operations (typically 3-4) separated by about 3 months between each.
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.
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.
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.
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.
I hope this is useful. If there are any questions, please feel free to get in touch.