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Shaaban et al. Plast Aesthet Res 2023;10:12 https://dx.doi.org/10.20517/2347-9264.2022.91 Page 7 of 16

Understanding the incidence of postoperative complications following breast augmentation with fat grafting
could enhance the collaborative decision-making process between patients and healthcare providers in
determining whether fat grafting is a preferential alternative to conventional breast implant-based
techniques in specific cases. The majority of fat grafting reported complications include asymmetry, skin
irregularities, oil cysts, calcifications, palpable cysts, fat necrosis, infection, hematoma, and seroma. The
incidence of these complications varied among the studies, with oil cysts and calcifications being the most
frequently observed radiologic changes. The formation of oil cysts ranged from 0-83%, with a reported
incidence of 6.5% following radiologic analysis. Calcification incidence ranged from 0-80%, with a reported
incidence of 4.5% following radiologic analysis. The incidence of fat necrosis varied from 0-10%, with a
reported incidence of 1.2% following radiologic analysis. Palpable cysts ranged from 0-15%, with 40%-100%
requiring aspiration. The incidences of infection, hematoma, and seroma were under 5% [24,89-91] .

There has been an evident concern raised in the literature regarding the possibility that fat grafting could
promote cancer recurrence; however, an abundance of clinical evidence has yet to demonstrate any clear
statistical correlation between cancer recurrence and autologous fat grafting in the majority of patients [81,92] .
Further, the mixed use of implants with fat grafting in reconstructive surgery does not appear to have any
impact on cancer recurrence and may reduce implant-associated risks, including fibrosis and capsular
contracture [23,93-95] . Similarly, fat grafting used with implants in patients with BRCA mutation undergoing
prophylactic mastectomy or in patients who have had implants removed due to breast implant-associated
anaplastic large cell lymphoma (ALCL) has not demonstrated any increased risk of tumorigenicity [96-98] . Of
note, a 2013 study by Petit et al. showed a higher risk of a local oncologic event in intraepithelial neoplasia
patients following lipofilling compared to a matched cohort (59 and 118 patients in each respective group)
[99]
and thus, fat grafting may need to be avoided in patients belonging to this subgroup . Moreover, there has
been significant concern regarding fat necrosis and calcification in the breast and its effects on the accuracy
of mammography, particularly in patients who are receiving fat grafting after breast cancer surgery.
Multiple studies have addressed the detection of subsequent malignancy in the setting of fat necrosis. One
such comprehensive systematic review, which incorporated a cohort of 4,601 patients who underwent breast
fat grafting for the purpose of augmentation and reconstruction, was conducted to evaluate the incidence of
radiographic abnormalities at 12 months post-procedure. The results of this review revealed that 13% of
patients developed radiographic abnormalities, which is comparable to the rate of radiographic
abnormalities observed following other procedures involving the breast. Another retrospective analysis of
mammography reports of 31 patients who underwent fat grafting was conducted, which revealed the
presence of microcalcifications, macrocalcifications, and cysts in postoperative mammograms; however, all
lesions were classified as benign according to the Breast Imaging Reporting and Data System II. A
comparative analysis of 20 pre- and post-graft mammograms was performed, and no statistically significant
difference in breast tissue density or in the Breast Imaging Reporting and Data System II assessment
category was observed after fat grafting. Together, these findings provide evidence that fat grafting does not
impede mammographic follow-up [75,100,101] .

Patient selection
Candidates must be carefully selected depending on their acceptance for multiple surgeries, availability of
satisfactory and sufficient donor sites, the patient’s physical and psychological health condition, and no
active cancer or recurrence within 6 months of surgery . Fat grafting outcomes are more favorable in a
[48]
nonirradiated breast after mastectomy, and if the reconstruction involves only one breast rather than two.
In instances where fat grafting is used following implant failure, replacement of the failed implant with fat
grafting has been proposed as an option for those that cannot tolerate lengthy flap procedures or those who
had recurrent prosthetic infections either due to being high-risk patients or comorbidities that make them
unfit for anesthesia. [9,23,69] .