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Shaaban et al. Plast Aesthet Res 2023;10:12 https://dx.doi.org/10.20517/2347-9264.2022.91 Page 5 of 16

[8]
breast . Though fat grafting has been used for years, researchers and clinicians have yet to come together
on an evidence-based, standardized protocol for its use, the steps of the procedure, or a measure of its
[66]
outcome . Therefore, a variety of techniques and approaches have been used for every step of the
procedure, from donor and recipient site preparation, harvesting and processing to reinjection and follow-
up procedures. However, most plastic surgeons follow Coleman’s principles in which fat is first
concentrated with centrifugation and then injected in small parcels using multiple passes [67,68] .

Patient selection
Candidates for fat grafting with breast reconstruction are selected depending on the patient’s acceptance of
possible multiple surgeries, the availability of satisfactory donor sites, and the patient’s physical and
psychological health condition . It is not favorable if the patient is a smoker or belongs to a high-risk
[48]
group, including diabetic, obese, and of advanced age [56,69] . Throughout the preoperative assessment, gauging
the patient’s mindset and expectations of fat grafting is crucial to outcome success and the patient’s
satisfaction. Patients should be informed of the extent of the procedure and possible outcomes to prepare
them psychologically for the surgical journey and avoid early disappointment if not well-informed. For
example, for some patients, the first fat grafting session does not yield significant volumization and is used
to prepare the skin of the recipient site by increasing pliability. Thus, graft resorption is to be expected . To
[13]
aid in this process, photographs of both donor and recipient sites from different angles can be used to
provide a blueprint for both the surgeon and the patient to track the changes and compare the preoperative
outlook with the postoperative outcome.

Safety is another important issue to discuss with the patient to eliminate any misunderstanding and explain
the frequency of breast imaging needed after the surgery in case of post-cancer reconstruction and the
possibility of recurrence and its relation to fat grafting [9,49,70] .

TOTAL AUTOLOGOUS BREAST RECONSTRUCTION
Recently, fat grafting has been used independently for primary augmentation, total breast reconstruction,
and post-implant replacement, making it an increasingly accepted alternative to the more invasive
approaches, especially in small to moderate-volume breasts [47,71-73] . Despite the aforementioned fat grafting
drawbacks, using autologous tissue may be preferable to prosthetics for many patients as it does not have
implant-related risks and gives a more natural look and feel in comparison [13,46,47,60,74-76] . High satisfaction
rates have been described by Dayal, Bhatia, and Hsu, with over 86.5% of patients reported to have either
good or very good results judged by an independent panel of surgeons with a mean follow-up of 12
months . Similarly, Groen et al. demonstrated that 92% of patients and 89% of surgeons were satisfied with
[47]
the results. Finally, fat grafting for breast reconstruction has been linked to psychosocial well-being and
improved sexual satisfaction [41,77,78] .

Total breast reconstruction with fat grafting is recommended for women requiring small to moderate
volume augmentation, such as breast-conserving mastectomy (lumpectomy) to fill contour defects [9,46,48,60] . It
is also recommended to minimize significant asymmetry and to improve cleavage appearance by adjusting
[9]
intermammary distance . Along with its application in congenital anomalies, including tuberous breast
deformity and Poland syndrome, fat grafting is used to correct breast hypoplasia and to fill the sub-
clavicular and anterior axillary fold defects [48,70,79] . In patients desiring removal of their implants and in cases
of implant complications, including malposition, rupture, pain, asymmetry, size change, and capsular
contracture, fat grafting is an option to restore lost volume .
[64]