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Page 6 of 16 Shaaban et al. Plast Aesthet Res 2023;10:12 https://dx.doi.org/10.20517/2347-9264.2022.91

The outcome of total breast reconstruction with fat grafting can often be better than conventional methods;
fat is autologous and readily available, and harvesting and injecting are easily performed [13,75] . The hospital
stay in fat grafting alone without any other procedures is often short and the patient is discharged sooner.
Ecchymosis and edema are expected in the breast or donor site that usually subsides within 3 weeks after
surgery. The long-term result of the operation is most accurately assessed starting 3-6 months post-surgery
[80]
up to a year to assess the extent of resorption .
Reconstruction surgical timing and irradiation considerations
Aside from primary reconstruction in aesthetic cases and congenital anomalies, there is no standard
timeline for reconstructive fat grafting after primary surgical care. Traditionally, in cases of breast cancer, fat
grafting is performed several months after primary reconstruction at the end of oncologic treatment [40,43,44,51] .
Radiation therapy following lumpectomy is believed to adversely affect fat graft survival, making the graft
more susceptible to ischemia, fibrosis, and necrosis; thus, fat grafting is delayed in these instances until the
[81]
completion of oncologic treatment . Alternatively, fat grafting used on irradiated expanders is believed to
[82]
reduce ulceration and implant exposure . When fat grafting is used after the removal of an implant, the
best outcomes are achieved when grafting is performed immediately to take advantage of tissue laxity .
[23]
Safety and complications
The main drawback of the fat grafting procedure is unpredictable long-term graft survival and the lengthy
process potentially requiring several surgeries with 3 months intervals in between . Furthermore, as fat
[47]
grafting is recommended for those with smaller breast sizes, these patients often do not have enough excess
donor material for multiple harvesting requirements. In contrast, those with abundant fat reserves tend to
have larger breast sizes that present difficulty in achieving symmetry [13,80] . Finally, weight fluctuation
immediately prior to or during graft integration periods has been noted to adversely affects outcomes [8,80] .

When large volume replacement is necessary, one session of fat grafting is typically not favorable as boluses
of avascular fat lead to central necrosis, adipocyte lysis, oil cyst accumulation and calcification. Hence,
multiple sessions with moderate injection volumes are needed to achieve the targeted outcome, which may
dissuade patients from requiring large-volume replacement . To address this issue, pre-expansion by either
[8]
external or internal expanders has been suggested [12,83] . However, proposed devices, such as the Brava, are
[84]
not broadly available commercially, and when available, require arduous patient compliance .

Fat grafting complications can be classified as occurring at the donor site, recipient site or systemically.
[8]
Donor site complications are dependent on the liposuction technique and the surgeon's skill , and may
include swelling, bruising, dimpling, hematoma, seroma, pain, infection, paresthesia, hypertrophic scarring,
and contour irregularities. Injury to the underlying structures due to cannula penetration is possible but
rare. Recipient site complications include infection, resorption, ecchymosis, striae, hematoma, fat necrosis,
oil cyst formation, calcification, asymmetry, and failure of graft take, along with persistent pain [23,48,70] .
Systemic complications are infrequent and include sepsis, septic shock, pneumothorax, fat embolism, and
stroke .
[85]
While overall complications are relatively low, the rates are higher in patients that have had radiotherapy
following modified radical mastectomy and skin-sparing mastectomy [23,86] . Smoking is another factor that
could cause unexpected complications, and lastly, larger volume grafting in one session is related to a higher
rate of complications [87,88] .