Can Breast implants 4 years after DIEP flap reconstruction help fill out upper pole? (Had fat injections and it all absorbed)

That question is an interesting one, but perhaps the answer is not as complicated as it might seem.  Given the information your provided the following might be a suitable approach.  If you have more flap skin than is needed, you could have some of that removed in the upper portion and then re-advance a fat only portion of the flap under the superior mastectomy flap to augment the upper pole.  Additionally, a second attempt at fat grafting might be in order after the above described procedure (into the new tissue re-positioned there.  A loss of 85% is very high.  With a change in technique you might be able to achieve higher take rates.  If these two maneuvers don't provide the needed volume, then an implant would be warranted.  Those maneuvers will not have been done in vain as they will provide more natural coverage over an implant.

Yes, placement of implants under a DIEP flap reconstruction is a common method of "augmenting" the volume of your breast reconstruction. In your case, the DIEP flap lost volume with weight loss and fat injections alone may not be enough to give you the desired fullness. Therefore, implant placement can increase the volume and projection of the reconstructed breast to achieve a more pleasing shape. 

Absolutely, breast implants can be placed under the DIEP free flaps to add improved breast shape and fill the upper pole. This is usually placed below the flap and above the pec muscle. I would suggest a round implant with a smaller diameter. The reason for this small diameter is so that the implant does not compromise the pedicle (blood vessels) of the DIEP flap. Even after 4 years your flap may still be reliant on the blood vessels to the flap. Contoured or anatomic implants will likely rotate in this sub-flap pocket as it is not a strongly adherent region. Also would suggest revisiting the idea of fat grafting the upper pole as it is generally a successful operation.  

You have a very complicated issue.  Yes you can have implants.  I would recommend that you go to your original surgeon or another very experienced DIEP flap surgeon.  Did you have surgical weight loss so that this happened very quickly?Three basic forms of breast reconstruction exist. You can use your own tissue, implants or a
combination of the previous two techniques.
Your own tissue can be used in the form of the DIEP flap, PAP flap, SGAP
flap or fat grafting. Implants can be
done in one stage or two stage. Two
stage reconstructions are started by placing expanders at the time of mastectomy. Once they expanders are placed they are able
to be inflated as determined by wound healing. The final time consists of
combining any of the above techniques.



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aspects of facial surgery, breast augmentation and body procedures including
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