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Page 2 of 16 Shaaban et al. Plast Aesthet Res 2023;10:12 https://dx.doi.org/10.20517/2347-9264.2022.91

required surgical procedures and enabling on-table results to reflect procedure outcomes.

Keywords: Fat grafting, fat transfer, autologous breast reconstruction, implant reconstruction, lipo-injection, breast
augmentation, graft survival, skin expansion, mastectomy, post-mastectomy pain, breast fibrosis, capsular
contracture

INTRODUCTION
Reconstruction is a critical component of post-oncologic care for breast cancer survivors, and thus,
reconstructive procedures connected with mastectomy are protected by United States federal law by the
Women’s Health and Cancer Rights Act of 1998 (WHCRA) . The overall goal of breast reconstruction is to
[1]
achieve a better quality of life and body image, higher self-esteem and sexuality, and overall psychological
well-being . Towards these goals, immediate reconstruction has been found to reduce psychiatric
[2]
[3,4]
morbidity and body stigma in comparison to delayed reconstruction . Methods to optimize outcomes are
constantly evolving to address physical and psychological challenges associated with different types of
reconstructive procedures to facilitate survivors’ acceptance of oncologic care and avoid long-term negative
psychological effects .
[5-7]

Adipose tissue (fat) is a biocompatible and readily available filler with beneficial biologic effects not
observed with inert biomaterials. Indications for autologous fat grafting in the breast are rapidly expanding
and currently include deformity correction after mastectomy, augmentation, lumpectomy, mastopexy,
reduction mammoplasty, and implant reconstruction [8-11] . While initially used primarily as an adjunct
procedure to other reconstructive approaches, including implants or muscle flaps, the fat grafting technique
has evolved to inject increasingly larger volumes and is now also used for primary reconstruction [12,13] . The
benefits of using fat grafting for reconstruction include reduced morbidity compared to more invasive
procedures with similar outcomes . In this review, current applications of fat grafting in breast
[14]
reconstruction will be described with indications, outcomes, and possible complications, along with patient
selection criteria, preoperative assessment, variables that affect graft survival, possible challenges, and
techniques developed to overcome these challenges in comparison with conventional reconstruction
methods.

FAT GRAFTING SECONDARY TO TRADITIONAL RECONSTRUCTION
Conventional methods of breast reconstruction include implants/prosthetics, autologous flaps, or hybrid
flaps with an implant. The choice between reconstruction approaches is often based on several factors,
including the patient’s age, overall health condition, body type, lifestyle, breast size, amount of tissue
available for reconstruction, patient’s willingness to go through more than one surgery, and recovery time.
Other medical or surgical factors used to determine the choice of reconstruction include the extent of
oncologic surgery, the further need for post-mastectomy chemotherapy or irradiation, and whether
reconstruction is needed for one or both breasts. Additionally, insurance coverage and financial constraints
may be considered [15-20] .

Implant-based reconstruction
Breast implants remain the most common approach to breast reconstruction according to the American
[21]
Society of Plastic Surgeons (ASPS) report , likely due to the less invasive nature of the surgery and reduced
recovery time compared to flap-based reconstruction. Out of the 137,808 breast reconstructions reported by
ASPS in 2020, over 103,000 were implant-based, either exclusively or with a tissue expander. In implant-
based reconstruction, the implant is placed subpectoral or pre-pectoral and is done either in a single