By Frederick N. Lukash, MD, FACS, FAAP

Breast reconstruction following mastectomy has evolved. Originally silicone implants were placed in the defect pocket. Tissue expansion and the use of flaps for additional coverage of implants improved the outcomes. Flaps with bulk were used to create breast mounds without the need for an implant. The era of microsurgery made the choice of flaps more versatile.

A further advance in the algorithm of breast reconstruction involves the use of one’s own body fat. It has been used most often to “fill in” defects from shortcomings of both implant and flap surgeries.  It can, however, in selected situations, be used to create an entire breast.

A procedure called “SIEF” or Simultaneous Implant Exchange with Fat can be performed to replace implants that are functionally or aesthetically problematic. In this scenario, the breast implant is removed, and the volume is replaced with fat. The fat goes into the spaces between skin and muscle and between the envelope that surrounded the implant. This expansion collapses the space that housed the implant.  If the implant was large it may be downsized serially as volume increases with fat. This is necessary as there is a limit as to the amount of fat that can be grafted at any single session. With repeated grafting sessions a new breast can be made entirely from fat.

A caveat to all fat grafting is that you “rob Peter to pay Paul”. So, while Paul needs it Peter must have it. Some individuals may not be candidates and others may use fat grafting as a helpful adjunct to allow for smaller and more comfortable implants while maintaining adequate volume.  This is especially true if there is not enough fat for total replacement.

Another advancement with fat is the ability to create an entire breast from fat at the outset. Again, it is a staged serial procedure as there is a survival limit to the amount of fat that can be grafted at any one session.

Some surgeons can use a device called BRAVA to help enrich the recipient area and allow for greater volumes and survival.

Although the use of fat for total breast reconstruction requires multiple surgeries, they are relatively quick and all outpatient with rapid recovery.

There are no big incisions and limited risks for failure.

If you are a “patient” patient, and in the hands of a skilled surgeon trained in fat grafting, you can achieve a natural breast without big surgeries.