I am 23 and in one week I am having a bilateral prophylactic mastectomy with expanders to implants. I just heard about fat grafting. I am 5' 3", 115lbs and most of my fat are my D size breast. I plan to stay my size or a little smaller when I get implants & know I can't get to that size just by fat grafting. Is it safe if I decide to do a smaller implant then later do fat grafting to help give it a more natural feel? Is there much research about these yet?
Is Fat Grafting for the Breast Recommened or Safe After a Bilateral Prophylactic Mastectomy?
Doctor Answers 12
Fat transfer is recommended for breast reconstructions in some cases
Fat transfer is an excellent choice for mastectomy reconstruction in some cases, with exclusions. I encourage you to visit sites like the Miami Breast Center to view a very large series of mastectomy reconstructions. The procedure is very laborious, but in my opinion it is worth evaluating if it fits your personal options in terms of lifestyle.
There is a wealth of research on the matter, but it is not so easily available to patients, as most studies are relatively recent. Dr. Delay published a study in 2009 of 880 procedures performed over 10 years with no increased rate of breast tumors. Multiple others are available. The American Society of Plastic Surgeons published a position statement in 2009 that is available as well. The Annals of Oncology in May of this year published a study with 321 patients treated with "lipofilling" for breast reconstruction between 1997 and 2008 with no increased risk of tumor recurrence.
I recommend you contact a physician/center with experience on this matter, and explore your options. There is an ongoing FDA study on this matter as well.
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Prophylactic mastectomy and consideration for later fat grafting after immediate reconstruction
The present course of action that you have scheduled is prudent. Later on you can consider fat grafting to further embellish and augment your results. However, at your weight, you may not have bottomless resevoir of fat available for the fat grafting so I would not necessarily request smaller than reasonable implants.
Though usage of fat grafting in breast reconstruction and even for breast augmentation is becoming more popular and commonplace and we haven't seen any major health related risks in the short term, we still don't have enough information on whether or not there are any significant negative long term consequences.
Breast Reconstruction Using Fat Grafting
Breast reconstruction using fat grafting is a viable and safe alternative to expander-implant or free tissue transfer in the right circumstances.
There has been extensive research and clinical experience in this field. There have been several clinical teaching courses, including the Miami Fat Grafting course directed by Dr. Roger Khouri. See the links below.
You must have sufficient fat, however, to achieve the size you want, and this will be the limiting problem. If you have moderate excess fat, then perhaps a B cup, or about 200 cc per breast may be achievable.
The other issue is that the grafting is done in 2-5 stages and requires the use of an external tissue expander, called the Brava device. This device was first used to try to enhance breasts without implants or fat grafting. It has been found to be an essential and effective adjunct to breast enhancement or reconstruction with fat grafting alone.
It works be applying negative pressure to the breast over a period of weeks. This induces a rich vascular supply to the tissue under the skin. This vascular bed, as it is called, is then receptive to transplantation and permanent survival of your transferred fat.
I have attended this course and believe the results are credible.
If a patient is too thin, however, or wants more than the available fat that can be removed from their body can deliver, then expander-implant reconstruction is an excellent method to achieve a very natural breast reconstruction. In fact, with a nipple sparing prophylactic mastectomy, using an infra-mammary incision, a very natural and soft breast reconstruction with minimal visible scarring can be achieved.
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Is fat grafting for the breast recommended or safe after a bilateral prophylactic mastectomy?
At our Breast Reconstruction Center, we have utilizing this technique almost routinely to maximize the aesthetic outcomes after lumpectomy or mastectomy. We have utilized the micro-fat grafting technique, and have been obtaining maximal fat graft survival into the breast. After harvesting of the fat from areas with excess fat, usually the belly, hips, or thighs, the fat is processed and injected back into the breast using the aforementioned techniques. Our patients have been very happy with the results as well as the areas where the liposuction was performed. Contour has been much improved using the micro-fat grafting technique, and the downtime is minimal.
Fat grafting has become a mainstay in breast reconstruction and has added another edge to breast reconstruction for aesthetics with minimal morbidity and complications. Hope that this helps! Best wishes!
Fat grafting for breast reconstruction
Fat grafting for breast reconstruction is an option fo breast reconstruction for small to moderate sized breasts. One of the main limiting factors is the amount of fat you have to donate to fat grafting. At 115 lbs, you probably don't have a lot of donor sites.
There is not a wealth of research yet regarding this but preliminary studies are promising and more data is being collected and published every day.
Fat grafting techniques are improving which is leading to improved, longlasting take of the fat.
I hope this helps.
I assume you are BRCA positive. If so, I would also assume you have had discussions regarding the timing of mastectomies and/or oophorectomy. If not, you should do so. There are a number of very good surgeons in Houston to pick from. If you proceed, initial expander placement followed by implants is my preference. Skin and nipple/areolar sparing should be highly considered. With the newer gel implants & dermal matrix grafts, I almost never go sub-pectoral any more. With the size of implant needed, very little of it is covered by muscle and the consequences may be very problematic (pain, shoulder mobility, breast distortion, etc.). A two stage procedure allows control of the pocket after mastectomy (even with dermal matrix graft) and the volume selection to your satisfaction is more precise. Fat grafts for touch-up contouring and feathering is possible, but not as your primary method of reconstruction.
You are not a good candidte for fat grafting alone
You should ask your surgeon about nipple sparing mastectomy and see if you are a candidate. I would think that you do not have enough fat for fat grafting alone to give good result. Implant reconstruction and fat grafting later on can be a good option. You also ask your plastic surgeon about avoiding the expander and do the implant reconstruction post mastectomy if you are not getting radiation treatment. What is the reason for the mastectomy?
Fat grafting to the breast
Your plan is a good one. To be a D you'll need implants or DIEP flaps after bilateral mastectomies. If you choose implants, then fat grafting down the track will reliably improve the feel and naturalness, so go for it. Given your youth, you should not have flaps, implants would be the best option as it will not scar you elsewhere or affect future pregnancies through abdominal wall surgery.
Not sure why you need expanders if you can have a skin sparing mastectomy. However, this can be a good option as it allows your surgeon to control mastectomy flap skin tension in the early postop period.
It sounds like you are in good hands.
Good luck for your surgery.
Fat grafting after breast reconstruction
While it may be difficult to obtain a "D" cup with fat grafting alone, the use of fat grafting as an adjunct in breast reconstruction is becoming accepted. Fat grafting can be used to improve contour irregularities, rippling, or minor asymmetries following reconstruction. It is less commonly used to increase volume following breast reconstruction. These are questions you may want to discuss with your plastic surgeon. As to its safety, we do know that grafted fat may appear as calcifications on mammograms; however, it is believed to be safe to perform following mastectomy.
No evidence for fat grafting danger in the breast area
While there have been no direct studies looking in the future longterm after fat grafting, concerns about fat grafting resulting in mammographic abnormalites or impairing breast cancer diagnosis have been alleviated. The only problematic issue we see with fat grafting is absorption of the fat over time, and most maintain about 50% of the fat grafted. Second and third procedures may be performed to reach a better end point. I have enjoyed performing fat grafting to the breast in my practice. I think it's great for smoothing reconstructive patients or for achieving enhancement for cosmetic breast surgery.