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Shaaban et al. Plast Aesthet Res 2023;10:12 https://dx.doi.org/10.20517/2347-9264.2022.91 Page 3 of 16

procedure or as a two-staged approach in which a tissue expander is placed immediately and then
subsequently exchanged with an implant in a second procedure [22,23] .

Drawbacks of implant reconstruction include the development of contracture, rippling (especially in sub-
glandular reconstruction and thin patients) and/or undesirable physical appearances. For these reasons,
surgeons have evolved implant-based surgeries to include autologous fat grafting, either in one setting or as
a delayed surgical procedure, as an adjunct for improving contouring and correcting residual deformities. In
the two-staged approach, delayed fat grafting is performed to reduce irregularities or implant delineations
which may result from the implant folding over time [9,11,23-25] . Studies have shown high levels of patient
satisfaction and low complication rates with this technique [26-28] . Fat grafting can effectively improve the
overall breast contour and achieve a more natural-looking shape [29,30] . Delayed grafting is often favored as
the recipient tissue bed becomes more vascularized with time and yields increased graft retention.
Alternatively, pre-pectoral fat grafting may be performed before implant insertion to increase skin quality
and flexibility, improve vascularization, and achieve better overall aesthetic outcomes [24,25,31,32] . Sforza and
Spear (2021) proposed that the future of hybrid procedures should include creating a concept for hybrid
breast augmentation surgery that provides reproducibility, predictability, and better surgical outcomes
based on a safe 3D algorithm .
[33]

While implant reconstruction is an easier surgery in regard to the required surgical technique and patient
recovery, there are some drawbacks. Challenges of implant reconstruction include a high early and long-
term failure rate, especially when used following radiation therapy. As it is not always possible to address
implant failure or unnatural feel with adjunct fat grafting, many patients opt for flap-based
reconstruction . Further, autologous reconstruction can be more cost-effective in the long term compared
[25]
to implants when considering follow-up health care use required to address adverse events.

Reconstruction with autologous flaps
Flap-based reconstruction is a versatile, reliable, and autologous approach for breast reconstruction and
may utilize pedicled flaps such as latissimus dorsi (LD) flap, transverse rectus abdominis (TRAM) flap,
thoracodorsal artery perforator (TDAP) flap, or free flaps such as free TRAM, free muscle-sparing TRAM,
the deep inferior epigastric perforator (DIEP) flap, or superficial inferior epigastric artery (SIEA) flap. Other
rarely used free flaps are lumbar artery perforator (LAP) flap, Gluteal artery perforator (GAP) free flap,
Upper gracilis flap (either transverse TUG, vertical VUP, or diagonal DUG), profunda artery perforator
[34]
(PAP) flap, and lateral thigh perforator (LTP) flap . While implant-based reconstruction requires a shorter
operative time, autologous flap-based reconstruction such as latissimus dorsi (LD), transverse rectus
abdominis (TRAM), and deep inferior epigastric perforator (DIEP) flaps often yield more satisfactory
results for patients [35-39] . Sinna et al. and Bennet et al. reported flap-based reconstruction to provide higher
satisfaction and psychological and sexual well-being than implant-based reconstruction [40,41] .

Pedicled flaps are most useful in irradiated breast or secondary salvage operations in case of autologous free
flap failure. Fat grafting may be used as an adjunct to flap procedures to augment the overall volume and
improve contour deformities, minimizing rippling and dynamic distortion [23,40,42-44] . It is relatively common
to use fat grafting for secondary procedures after free flaps including PAP and DIEP flaps. Fat grafting may
be performed either in conjunction with the flap as a single procedure or as a secondary revision to avoid
damaging the flaps and/or circumventing an unfavorable recipient site . Fat grafting with flap
[45]
reconstruction has also been noted to have beneficial biologic effects in addition to correcting contour
deformities, including improvement of skin quality after mastectomy and radiotherapy [46-49] .