This article has been medically reviewed for accuracy by Lutherville, MD board-certified plastic surgeon Dr. Ricardo L. Rodriguez on September 2, 2020.
Seeing an aesthetic procedure all over social media can breed a strange sort of FOMO. (Hey, we’re not immune.) Yet it may be difficult to distinguish for-the-’Gram fads from truly “Worth It” tweaks. Which is why we’re launching a new series on RealSelf: Everybody’s Doing It. Each month, we’ll explore all sides of an of-the-moment cosmetic procedure, to bring you the uncensored truth about its efficacy and safety so you can decide if it’s right for you. Here, in our latest installment, we’re covering fat transfer breast augmentation.
It’s been dubbed the “natural boob job,” “implant-free breast augmentation,” and “minimally invasive breast enhancement”—names ripe with modern-day appeal, aiming to encapsulate what’s medically known as fat transfer to the breast. But the growing interest in this cosmetic surgery procedure—and, make no mistake, it is a surgical procedure—is being propelled by more than just clever marketing.
In recent years, the classic boob job has come under fire as a certain type of textured surface breast implant has been linked to a rare non-Hodgkin’s lymphoma called BIA-ALCL. A more nebulous condition known as breast implant illness (BII) has also been reported, but a clear evidence based understanding of what it is has not emerged. Of course, implants also pose more standard risks, like rupture and capsular contracture, in addition to requiring lifelong surveillance.
Despite these drawbacks, traditional breast augmentation with silicone or saline implants remains the most popular plastic surgery procedure in America, according to a 2019 statistics report from The Aesthetic Society. While the operation has, in fact, held the number-one spot since 2008, its numbers took a bit of a hit recently, dropping 15% between 2018 and 2019. In that same span, the demand for breast implant removal, or explant surgery, jumped by nearly 35%.
The recent rise of fat transfer to the breast
Fat transfer, via liposuction, to the breast has not always had a good reputation. In 1987 the American Society of Plastic Surgeons (ASPS) published a position paper advising against fat grafting to the breast. With the advent of more refined and safe fat grafting techniques pioneered by S. Coleman MD , fat grafting experienced a renaissance. Significantly, the ASPS reversed its position in 2007, and since then fat grafting has gained mind share with board-certified plastic surgeons, reporting a 37.3% spike since 2015. “About three years ago, we started seeing an increase in patients asking for fat grafting alone for breast augmentation to avoid implants,” says Beverly Hills, California, board-certified plastic surgeon Dr. Kelly Killeen. Before that time, she adds, many had never heard of fat grafting to the breast. “Now that’s specifically what they’re coming in to consult about.”
Board-certified Beverly Hills, California, plastic surgeon Dr. Sheila Nazarian attributes the uptick to both fear of BII and patients’ desire for a more natural appearance using their own fat. In many parts of the country, plastic surgeons report, women have been requesting smaller cup sizes for at least the past five years. And fat grafting lends itself well to modest gains, notes Dr. Ashley Gordon, a board-certified plastic surgeon in Austin, Texas.
In Seattle, board-certified plastic surgeon Dr. Lisa Sowder has also noticed a heightened interest in fat grafting to the breast, which she’s been performing for more than nine years. “It’s a popular breast augmentation procedure for both BII and non-BII patients who’ve explanted and want some volume restoration,” she says. While she concedes that many women’s breasts bounce back nicely post-explant without any intervention, certain patients—particularly those whose already thin breast tissue has been damaged by implants or the explantation process—can benefit from a little extra padding in certain spots. “I do fat transfer for maybe 1 in 15 of my explant patients—most of them don’t really need it,” she adds.
Not every surgeon is a fan of adding fat to the breasts, however, and not every patient is a candidate. Moreover, the procedure comes with its own set of risks and limitations. Successful fat grafting is an technique-dependent procedure. The way the fat graft is processed impacts both fat graft survival and the rate of complications. Ahead, we answer your most pressing questions about creating cleavage, enhancing lifts, and rebuilding and revising breasts with fat.
Fat grafting 101: How can I get a breast augmentation without implants?
Plastic surgeons can indeed make your breasts bigger without implants, using a two-step technique that involves liposuctioning areas of the body with excess fat—the belly, hips, flanks, and other exercise-resistant zones—and subsequently relocating that body fat, once purified, to the breasts.
Of course, this is a serious oversimplification of what experts know to be a painstaking and nuanced undertaking. “You have to be very gentle with the fat, with minimal handling and manipulation when you harvest it,” says Dr. Sowder, alluding to the removal and processing of the fat. The grafting process should be approached with an equal measure of care. “My goal is to weave the fat throughout the breast tissue in an even way, injecting tiny amounts with each pass,” says Dr. Killeen. “When we do it in that manner, the fat is more likely to get a blood vessel and to stay and live there permanently.
Depositing pea-size parcels of fat as opposed to one big blob not only gives the entirety of the fat bundle the best shot at picking up blood supply and surviving long term, but it also encourages stability, notes Dr. Sowder, since tinier blebs are more easily supported by the surrounding tissue.
Depending on where the fat is placed, it can enlarge the whole of the breast or deliver a more customized effect by rounding out select sections. “The upper pole is often targeted, because that’s where volume loss typically occurs—especially with breastfeeding, weight loss, and implant removal,” notes Dr. Sowder. (Bear in mind, she adds: The shrinkage seen with volume loss is not the same as sagging. When a breast deflates, its nipple usually maintains a reasonable position; when it droops, the nipple shifts downward toward the floor, and a breast lift is generally indicated.)
Here’s the thing though: Because fat lacks structure, it can’t give the round, projected shape that many breast augmentation patients desire. “If you want the look of a perky breast, you need an implant,” says Dr. Killeen. What’s more, fat isn’t powered to make you more than a cup size or so bigger. “A pretty significant percentage of breast augmentation patients want to be two cup sizes larger—and that’s just not obtainable with a single round of fat grafting,” she adds. “Really, the person who does the best [with fat transfer] already has a decent shape and is just looking for a step up in breast volume.”
After all is said and done, that step could wind up being smaller than expected, even when your surgeon does everything right. Fat behaves capriciously when uprooted from its place of origin and moved about the body, and not every morsel survives. This can be a result of the technique used for fat graft processing or other patient factors that are not well understood. In fact, roughly half of transferred fat may fail to thrive and be resorbed by the body within the first few months of surgery. Studies and surgeons cite wide ranges for fat “take”—how much sticks around—on the order of 30% to 80%. Breasts in which circulation has been compromised by previous surgery or radiation treatments tend to fall on the low end of the spectrum. After radiation, Dr. Killeen explains, “the blood vessels are thickened and don’t create the little offshoot vessels as efficiently, so you don’t get quite as good take.”) The radiated breast is a different circumstance. Here the initial round of fat grafting is not so much for volume gain as it is to transform and heal the radiated tissue. This is an effect on radiated tissue by the stem cells present in optimally processed fat grafts. For this reason alone fat grafting to the radiated breast should be considered a healing therapy rather than volume augmentation.
Surgeons say that whatever fat is still present at three months post-op is likely there for the long haul—barring weight loss. “Stable weight is one of my absolute criteria for doing fat transfer on a patient,” says Dr. Sowder. “The fat transferred will respond to weight loss and gain the same way it did when it was in the donor area. I’ve had patients get too busty with weight gain and have also had patients lose much of their fat when they leaned out with CrossFit.”
So while the main advantage of fat over implants is, of course, that there are no implants—sparing patients the maintenance and potential headaches that accompany the devices—an upside to implants is “knowing what sort of volume increase we’re going to get, right down to the cc,” Dr. Sowder says. “With fat, that’s not the case—and patients have to be able to live with that unpredictability.”
In what scenarios is fat used to increase breast size without implants?
Plastic surgeons can use fat for first-time cosmetic augmentations as well as for implant removals, revision surgeries, and breast reconstructions following lumpectomies and mastectomies—in other words: fat can upgrade almost any base-model breast surgery.
“There are just some problems you can’t solve with an implant,” says Dr. Killeen, noting that fat shines when it comes to correcting contour deformities and mild asymmetries; hiding visible implant edges; and thickening up the breast, to help it feel more natural to a woman undergoing reconstruction.
Even though fat grafting is a common tool in aesthetic breast surgery, “it’s still primarily used in breast cancer [treatment] reconstruction,” notes Dr. Gordon. Beyond obscuring irregularities, a properly processed fat graft that survives carries with it natural stem cells that can help rejuvenate the skin and tissue of those with radiation damage.
“I offer nearly every breast reconstruction patient fat grafting at their second or final stage procedure, as a ‘bonus’—this goes for both implant reconstruction and flaps,” says Dr. Karen Horton, a board-certified plastic surgeon in San Francisco. “I inject fat into the mastectomy skin flap, which is the padding you can pinch over your sternum.” While a thick skin flap can accept a fair amount of fat, she says, “if the layer [of tissue] over an implant is extremely thin, then very little, if any, fat can be injected there.” (Recipient sites need some degree of give and capacity—more on that ahead.)
With revisions, or secondary breast surgeries, “fat grafting is a great tool to smooth areas that are depressed or to conceal implant edges,” says Dr. Killeen. Dr. Gordon finds fat to be a godsend for patients with animation deformity, which is a complication that can affect patients who have implants placed under the muscle. When the pec muscles flex, the implants move, distorting the shape of the breasts. “There’s really no great treatment from the inside,” she says, “but we can inject fat along the lower breast and toward the sternum where the muscle inserts, to camouflage that deformity.”
Fat can also perk up pancaked breasts after implant removal. Dr. Gordon prefers to have explant patients wait about six weeks before potential grafting, allowing the implant pocket to close down and the skin to naturally retract, so she can adequately gauge the new size of the breast and the true degree of deflation or laxity. Other surgeons may opt to fat graft directly following explant.
Related: 7 reasons why breast fat transfer is on the rise
Can fat bolster the results of a breast lift without implants?
It can—and some surgeons say that fat is actually key to next-level lifts. “If I could add a little fat back on every breast lift patient, I would,” says Dr. Killeen. “Women who are droopy tend to be very hollow in the upper portion of the breast. They can still look great [with a lift alone], but fat is a nice way to refine the result.”
In Dr. Nazarian’s experience, “breast lifts initially look full up top, but after some months, gravity pulls the breast tissue to the base of the breast, making the top look scooped out.” In 99% of her breast lift patients, she says, she injects fat in that upper pole “so that once everything settles out, it will look like a nice ramp and not concave.”
When enhancing breast lifts with fat, Dr. Gordon likes to place the fat in multiple layers—dermis, breast tissue, and pectoralis muscle—“to maximize fat graft take and minimize complications,” she says. While she admits that “there’s still a lot of controversy about where specifically to best inject fat in the breast,” she’s found that adding a small amount of fat into the muscle during a lift—when the breasts are open and she can see the muscle clearly—“really helps with shaping [and] gives a nice long-term result.”
Not every mastopexy patient qualifies for supplementary fat grafting, however. “Sometimes the tissue is like fabric, and we just can’t fill it with fat, because fat doesn’t give structure,” Dr. Gordon reiterates. “That’s where implants can be helpful—they give a foundation, something to drape the skin over.”
Who is a good candidate for fat transfer to the breast?
Beyond having realistic expectations, what makes one suitable for this sort of borrowing of fat is possessing both a generous donor site (ample hips, say) and an accommodating recipient site (compliant breast tissue, in other words). Generally speaking, patients should not expect more than one cup size change.
While having pudge to spare is a no-brainer prerequisite, less obvious, perhaps, is what makes one breast more amenable to fat grafting than another. “The very best patients are those whose breasts are more on the fatty side and who have loose tissues from weight loss or breastfeeding,” explains Dr. Sowder. Dense breasts—bearing more firm, fibrous glandular tissue and less soft, yielding fat—are generally harder to graft, particularly if the woman also has taut skin. “That’s a challenge, because things get so tight, so quickly,” notes Dr. Sowder.
Stuffing fat into tight quarters is, by all accounts, ill-advised. “Fat placed under tension cannot both expand the tissues and recover a blood supply in order to survive,” explains Dr. Roger Khouri, a board-certified plastic surgeon in Miami. “Therefore, [any] enlargement is only temporary, and non-surviving fat will either get resorbed [by the body] or turn into cysts or worrisome nodules that will need to be biopsied, to make sure they’re not cancerous.”
Because large-volume fat transfer is linked to a higher prevalence of fat necrosis, surgeons may choose to incrementally build the breasts, injecting small amounts of fat over several sessions, when appropriate. Dr. Sowder has done multiple rounds on just a handful of patients but stresses that “it’s super-important to stop when there’s a risk of leaving divots or contour defects in the donor areas. I’ve said no to many patients wanting just a little bit more. I call this ‘breast greed’—it’s a thing.”
Ultimately, it’s rare that someone will tolerate more than one surgery. “I usually tell my patients that if I have to do more than one fat transfer, it’s probably better to just get an implant,” Dr. Nazarian says.
Can anything be done to improve fat “take”?
Though it’s hardly standard protocol, pre-expansion is a concept some plastic surgeons swear by for enlarging the recipient bed and improving circulation to make breasts more hospitable to fat.
About 20 years ago, Dr. Khouri invented a wearable vacuum-suction device called the Brava, which was designed, studied, and sold for this purpose. He recently revamped the tech (now known as the External Vacuum Expander or EVE), to make it more efficient. When worn for 200 hours in the 15 days prior to fat transfer, the bra-like apparatus temporarily stretches out the breast, he explains, “creating room to better disperse the graft, which can then passively occupy and settle in an already enlarged space.” When patients wear the device as directed, “we typically double the volume of the native breast with a single round of fat grafting,” Dr. Khouri says.
Over the past two decades, numerous studies have found his approach of preceding fat grafting with external expansion to be safe and effective for both cosmetic augmentations and breast reconstructions in mastectomy patients. In cases of reconstruction, “treatment with EVE re-creates a [temporary] breast mound prior to grafting,” he says. “With two to three successive fat grafting sessions, three months apart, we regenerate a sensate, normal-feeling, beautiful breast that contains only fat—none of the breast components that can turn malignant.”
The technique can also help rebuild difficult-to-treat radiated breasts. “Although not too many grafts survive on the first grafting session, if they are EVE-expanded, more will take, which will make for a better recipient on the subsequent sessions. By gradually repopulating a radiated site with healthy fat, over the course of two to four sessions, we can reverse the radiation damage,” Dr. Khouri claims.
With the exception of Dr. Khouri, none of the surgeons we interviewed use the contraption to prime breasts for fat grafting, insisting they get good results without it and that patients find the Brava uncomfortable and impractical. “I can’t totally dismiss it, because I think the science behind it is very good, but it’s extremely onerous and can cause a lot of skin problems,” says Dr. Sowder, referring to the original Brava design. Dr. Killeen has also seen a variety of Brava-related complications, like blisters and hyperpigmentation issues, in patients who used the device at the behest of other surgeons, in addition to cysts and nodules resulting from large-volume fat necrosis following pre-expansion with the Brava, she adds.
As an alternative to this mechanical stretching, surgeons will sometimes use an established surgical technique called expansion vibration lipofilling, or EVL, in patients with small, tight breasts to “make the recipient site a little bigger and give grafts a better chance at survival,” Dr. Gordon says. This preliminary step involves inserting a special cannula with a flared or “exploded” tip and passing it back and forth through the different layers of the tissue multiple times, to loosen the skin envelope. However, this technique can have the pitfall of creating large hollow spaces where clumps of fat may agglomerate without the required blood flow needed for survival. This is a set-up for complications such as cysts and fat necrosis.
If tissue damage incurred by cancer treatment poses a threat to fat survival, Dr. Killeen may aim to augment take by adding platelet-rich plasma to a patient’s breasts during surgery and having them wear the Prevena, a wound-care vacuum, as a post-op dressing in the days following in order to help dilate blood vessels under the skin. “We’ve been using it pretty extensively with mastectomy patients over the past five years and have seen improved fat take with it, especially in those with a history of radiation.”
Sounds amazing… but are we sure it’s safe to inject fat into the breasts?
In the early days of fat grafting, there were concerns that adding fat to the breast could spark carcinogenic changes or hike risk of recurrence in cancer survivors. But over time, numerous long-term studies—here, here, and here, for instance—have found fat transfer to the breast to be “safe to perform in both cosmetic and reconstructive breast surgery,” says Dr. Rod Rohrich, a board-certified plastic surgeon in Dallas and the editor-in-chief of the medical journal Plastic and Reconstructive Surgery.
“It is now well-established that fat grafting the breast does not increase the likelihood of cancer,” adds Dr. Khouri. Problems arise, however, when non-surviving fat cells calcify or form cysts rather than being resorbed by the body. According to a 2019 study on fat transfer for breast reconstruction, “the reported incidence of oil cyst and fat necrosis in the literature is between 3% and 17%.”
“The most dangerous thing about fat grafting to the breast is to assume such palpable nodules are fat necrosis without ruling out cancer first,” adds Dr. Khouri.
This is where things get controversial. Some surgeons are firmly against altering the anatomy of the breasts with fat. Dr. Horton, for one, refuses to fat graft healthy, natural breasts, believing that potential cysts and calcifications can interfere with mammogram screenings, hinder breast cancer detection, and lead to unnecessary biopsies. She reserves the procedure for breast reconstruction patients “after a mastectomy for breast cancer or as a risk-reduction surgery in BRCA+ women, when no additional mammograms are performed because all of the breast tissue has been removed,” she says.
Other surgeons contend that the lumps resulting from fat necrosis look very different from breast cancers and that skilled radiologists can handily distinguish one from the other. A 2019 paper in the journal JAMA Surgery supports this position, referencing various studies that have “demonstrated that macrocalcifications resulting from fat necrosis after AFT [autologous fat transfer] do not seem to hinder the detection of breast cancer.”
Moreover, Dr. Sowder makes the point that “any breast surgery will have mammographic implications, with internal scarring that can make interpretations more difficult.” Exploring this assertion further, a team of researchers led by board-certified Pittsburgh plastic surgeon Dr. J. Peter Rubin conducted a blinded study comparing breast changes visible in mammograms following fat grafting to those seen in imaging after breast reduction surgery and found fat grafting produced fewer radiographic abnormalities. Regardless, adds Dr. Khouri, “it is crucially important that all nodules be worked up and cancer be ruled out.”
What’s the downtime following fat transfer to the breast?
While liposuctioned areas can ache for days, the breasts tend to fare a bit better. “The only complaint we hear is that they can be quite swollen and bruised after fat grafting,” says Dr. Killeen. “I always tell my patients pre-op, that’s the amorphous blob phase of recovery—they don’t have cleavage, they’re just a swollen blob,” says Dr. Killeen. By three to four weeks out, swelling subsides and the new breast shape becomes apparent—though it’s a good idea to wait six to eight weeks before getting resized for bras.
Surgeons have patients in compression garments for one to two months, to help with healing after lipo and suggest wearing a camisole, a soft bra, or no bra at all, for the first week or two.
Plan on taking one week off work and skipping strenuous exercise for roughly two weeks. “By about one month,” Dr. Killeen says, “most patients are back to doing pretty much anything they want.”
